Abstract
Although eating disorders once were considered to occur most frequently among White upper middle class female adolescents, they are now known to affect all racial and ethnic groups. For African American youth, the prevalence of binge eating, which is associated with bulimia nervosa, binge eating disorder, and obesity, is equal or higher compared to all other racial and ethnic groups. Not surprisingly, African American youth also have the highest overweight and obesity prevalence rates when compared to any other racial and ethnic group in the USA. Despite the increased presence of disordered eating attitudes and behaviors and obesity in African American youth, research in this area remains quite limited. This chapter summarizes current research on eating disorders in African American youth. Risk factors for African American youth are discussed. Finally, culturally relevant treatment approaches for African American youth presenting with disordered eating attitudes and behaviors are provided.
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Keywords
- Eating disorders
- Binge eating
- Bulimia nervosa
- Obesity
- Overweight
- Disordered eating attitudes
- Risk factors for eating disorders in African American Youth
- Disordered eating behaviors
Introduction
Although eating disorders once were considered to occur most frequently among White upper middle class female adolescents, they are now known to affect all racial and ethnic groups (Franko, Becker, Thomas, & Herzog, 2007; George & Franko, 2010; Grabe & Hyde, 2006; Smolak & Striegel-Moore, 2001; Swanson, Crow, Le Grange, Swendsen, & Merikangas, 2011; Taylor, Caldwell, Baser, Faison, & Jackson, 2007). For African American youth, the prevalence of binge eating, which is associated with bulimia nervosa, binge eating disorder, and obesity, is equal or higher compared to all other racial and ethnic groups (Cassidy et al., 2012; Johnson, Rohan, & Kirk, 2002; Swanson et al., 2011; Taylor et al., 2007). Not surprisingly, African American youth also have the highest overweight and obesity prevalence rates (36 %) when compared to any other racial and ethnic group in the USA (Ogden, Carroll, Curtin, Lamb, & Flegal, 2010). Despite the increased presence of disordered eating attitudes and behaviors and obesity in African American youth, research in this area remains quite limited. This chapter summarizes current research on eating disorders in African American youth. Risk factors for African American youth are discussed. Finally, culturally relevant treatment approaches for African American youth presenting with disordered eating attitudes and behaviors are provided.
Eating Disorders Research in African American Youth
According to the Diagnostic and Statistical Manual of Mental Disorders-V (DSM-V; American Psychiatric Association, 2013), anorexia nervosa (AN) is characterized by distorted self-perceived weight or body image, persistent behavior that interferes with weight gain (i.e., energy intake restriction), and intense fear of gaining weight or of becoming fat. Bulimia nervosa (BN) is characterized by recurrent episodes of binge eating, recurrent inappropriate compensatory behaviors (e.g., purging) to prevent weight gain, and self-evaluation that is influenced by body shape and weight. Binge eating disorder (BED ) is defined as recurring episodes of binge eating (i.e., excessive consumption of food within a short period of time) with the absence of recurring compensatory behaviors and the binge eating episodes are marked by feelings of lack of control. Although obesity is not included in the DSM-V since it is not considered a mental disorder, its definition will be included in this chapter given the high rates of binge eating and obesity in African American youth. Obesity is defined as having a body mass index (BMI) at or above the 95th percentile for children of the same age and sex (http://www.cdc.gov/obesity/childhood/basics.html).
Studies documenting eating disorders in African American children and adolescents are scarce. One of the reasons why research in this area might be limited is the fact that African American females generally are considered to be more satisfied with their bodies due to cultural acceptance of larger body ideals in the African American community and, thus, may be less vulnerable to experiencing eating disorder symptoms (i.e., drive for thinness, body dissatisfaction) associated with traditional eating disorders (i.e., AN or BN; Franko & George, 2009; Smolak & Striegel-Moore, 2001; Swanson et al., 2011; Talleyrand, 2010; van de Berg, Mond, Eisenberg, Ackard, & Neumark-Sztainer, 2010). However, researchers have also found that African American boys and girls tend to engage in binge eating behaviors at rates that are equal or higher to their White counterparts (Cassidy et al., 2012; Johnson et al., 2002; Swanson et al., 2011; Taylor et al., 2007). For example, Johnson et al. (2002) studied binge eating behaviors in a sample of 822 White and African American adolescents and found that African American boys endorsed the highest rate of binge eating (26 %) while binge eating rates for African American girls, White boys, and W hite girls were approximately 18 %. Also, Taylor et al. (2007) examined binge eating behaviors in a large sample of Black and African American adolescents and adults and found that male adolescents had more cases of AN, BN, and binge eating than female adolescents. Finally, Swanson et al. (2011) investigated the prevalence and correlates of AN, BN, and BED in a large, diverse sample of adolescents and found that Black adolescents had the highest prevalence rates of sub-threshold BED when compared to Latino and White adolescents. Collectively, these findings suggest that binge eating behaviors may be more common among African American adolescents and both young males and females may be at risk for engaging in this type of eating disorder symptoms.
The majority of published studies examining eating disorder symptoms in African American youth support the fact that African American youth experience fewer restrictive eating behaviors (i.e., dieting) and body image concerns, but more binge eating behaviors, yet these findings have not been consistent in all cases. In fact, some researchers have found empirical evidence that supports body dissatisfaction, weight concerns, and unhealthy weight control behaviors (i.e., dieting, fasting) in African American adolescents (e.g., Granberg, Simons, Gibbons, & Melby, 2008; Pernick et al., 2006; Robinson, Chang, Haydel, & Killen, 2001). For example, Robinson et al. (2001) conducted a study of overweight concerns and body dissatisfaction among racially/ethnically diverse third-grade children and found that African American girls had significantly more overweight concerns than did Asian American and Filipino American girls. These mixed research findings could be a consequence of the use of different assessment methods or could suggest that cultural factors may no longer protect African American youth as once was assumed (Granberg et al., 2008; Robinson et al. 2007).
In summary, the literature on disordered eating attitudes and behaviors in African American youth has yielded some inconclusive results. Generally, findings indicate that dieting and body dissatisfaction are less likely to occur in African American youth relative to other racial and ethnic groups, although binge eating occurs to a similar or even greater extent. This could be one potential explanation for why African American youth experience the highest prevalence of overweight and obesity compared to all racial and ethnic groups. However, the fact that some empirical evidence confirms the presence of restrictive behavior and body image concerns in African American youth and that being obese potentially may lead to increasing eating disorder symptoms in African American youth (Dalton et al., 2007; Kelly, Bulik, & Mazzeo, 2011) warrants researchers to give more attention to this area. Furthermore, although African American youth may have more flexible definitions as to what are considered “acceptable” weight and body ideals this does not necessarily apply to all African American youth, nor does it mean that they do not experience problematic eating concerns (Kelly et al., 2011). That is, how African American youth manifest their eating disorder symptoms may vary from traditional eating disorder etiology.
Potential Risk Factors for African American Youth
Several researchers have suggested that African American cultural norms protect African American youth from experiencing high levels of body dissatisfaction (Franko & George, 2009; Smolak & Striegel-Moore, 2001; Swanson et al., 2011; Talleyrand, 2010; van de Berg et al., 2010). However, research has also shown that African American youth (both girls and boys) engage in binge eating behaviors and, to a lesser extent, restrictive eating behaviors and weight concerns. The assumption that African American youth may be protected from experiencing negative body image may mask the fact that some overweight and obese African American children are unhappy with their size and experience associated levels of psychological distress (e.g., depression) (Kelly et al., 2011; Olvera et al., Robinson et al., 2001; Witherspoon, Latta, Wang & Black, 2013). Furthermore, African American youth who are satisfied with their bodies may experience different pressures regarding beauty and body esteem yet the traditional methods of evaluating these factors (e.g., use of weight, body parts) may not capture the real body appearance concerns of African American youth. For example, additional factors such as hair, skin color, and social comparisons with other Black women have been found to be more relevant when evaluating the body esteem of Black women (Poran, 2006). In addition, the increasing presence of Black celebrity media images may sometimes serve as a misrepresentation of Black women and men, and contribute to the struggles that African American youth experience regarding weight, body image, and overall appearance (Poran, 2006). In order to evaluate effectively the presence of eating disorder symptoms in African American youth, clinicians should explore African American youth’s responses to various social, racial, cultural, and socioeconomic factors, which may serve as risk factors that go beyond the traditional risk factors (i.e., body dissatisfaction) assessed in the eating disorders literature.
Acculturation
Acculturation refers to adopting the norms of the majority culture, including adjusting to a new language, customs, and rituals (Helms & Cook, 1999; Kim & Abreu, 2001). Acculturation has been suggested to play a role in the development of eating disorders such that African American girls who value European American cultural norms of thinness may exhibit severe dieting behaviors and body dissatisfaction that are consistent with anorexia and bulimia (Dounchis, Hayden, & Wilfrey, 2001; Smolak & Striegel-Moore, 2001). Furthermore, researchers have found that high levels of acculturative stress may result in a greater number of bulimic symptoms and body dissatisfaction (Perez, Voelz, Pettit, & Joiner, 2002). On the contrary, maintaining African American cultural values may protect African American girls from endorsing eating behaviors and attitudes characteristic of anorexia and bulimia given that social pressures regarding thinness may not exist within African American culture (Abrams, Allen, & Gray, I993; Logio, 2003; Smolak & Striegel-Moore, 2001; Thompson, 1994). Furthermore, obesity may not be stigmatized in African American culture as it is in the dominant European American culture (Smolak & Striegel-Moore 2001; Thompson, 1994). Finally, belonging to a collectivistic culture (i.e., African American culture) may result in less focus on individual body size and more focus on using larger ethnic group body norms as a reference point (Fernandez, Malacrne, Wilfley, & McQuaid, 2006). It is important to note, however, that adopting African American cultural norms may be related to higher levels of other unhealthy eating practices (e.g., binge eating) because this mode of coping with emotions is acceptable within the African American community and does not necessarily violate cultural standards of beauty of the African American cultural group (Harris & Kuba, 1997; Smolak & Striegel-Moore, 2001; Thompson, 1994). In sum, it appears that evaluating cultural values regarding food and body image in African American youth may be a valuable tool in understanding the development of eating disorders in this population.
Racial and Ethnic Identity Development
Racial identity differs from the concept of acculturation in that it refers to how individuals understand themselves as racial beings. The concept of racial identity is related to the extent to which the person identifies with the racial group to which he or she supposedly belongs with the belief that commitment to one’s racial group is necessary for healthy psychological functioning (Helms & Cook, 1999). Ethnic identity refers to the extent people accept, identify with, and affirm their ethnic heritage (Phinney, 1992). Researchers have suggested that high levels of ethnic and racial identity may assist ethnically diverse women in rejecting the societal beauty ideals of the dominant culture (Harris, 1994; Shuttlesworth & Zotter, 2011; Wood & Petrie, 2010).
Only a few studies to date have examined the relationships between racial or ethnic identity and eating disorder symptoms in African American women. A common finding using Helm’s Black Racial Identity Model (BRIAS) has been that African American women who idealize Whiteness or use White-identified schemas (e.g., pre-encounter) tend to engage in restrictive forms of disordered eating attitudes and behaviors (e.g., dietary restraint, body dissatisfaction) (Abrams et al., 1993; Harris, 1994). Other researchers using the revised version of the Cross Racial Identity Scale (Cross & Vandiver, 2001; Vandiver et al., 2002) have found that self-hatred of African American group membership has a direct effect on maladaptive eating behaviors (e.g., bingeing/purging behaviors) as well as a significant indirect effect on maladaptive eating behaviors through body dissatisfaction (Flowers, Levesque, & Fischer, 2012). In the studies examining the link between ethnic identity and eating disorder symptoms, lower levels of ethnic identity in women of color have predicted higher rates of eating disorder attitudes and behaviors in African American women (Henrickson, Harrington, & Crowther, 2010; Shuttlesworth & Zotter, 2011; Wood & Petrie, 2010). Overall, results from these studies investigating the link between racial and ethnic identity development and eating disorder pathology in African American females suggest that low levels of racial and ethnic identity development influence the body evaluation and satisfaction of African American women as well as the use of disordered eating attitudes and behaviors.
Although no studies to date have looked at the relationship between racial identity and eating disorder symptoms in African American youth, it can be assumed that these results may be applicable to a younger population because African American children may also be exposed to discrimination, racism, and race-related events (Constantine & Blackmon, 2002; Day-Vines, Patton, & Baytops, 2003; Holcomb-McCoy, 2005). Simply put, African American youth who experience negative internalizations of African Americans may be at risk for developing disordered eating attitudes and behaviors. Therefore, understanding how African American youth respond to or internalize racism or race-related events may provide crucial information related to how they may manifest their eating disorder symptoms. For children and adolescents who identify as multiracial and/or multi-ethnic, they may experience additional stressors with respect to eating and body image concerns if cultural values from each group conflict. Although research and assessments in this area are strongly lacking, given that the number of children who identify as multiracial and/or multi-ethnic is increasing, additional research into this area is seriously warranted.
Socioeconomic Status
African Americans in the USA experience classism (e.g., disparate effects of social policy on low status groups) since they have less access to positions of power and authority than White men and women. Since there are a disproportionate number of African Americans who identify as low income, they are at risk for experiencing health concerns because they lack access to economic resources (Dounchis et al., 2001; Downing, 2004; Paul, 2003).
Empirical research supporting the relationship between socioeconomic status and obesity has been plagued with inconsistencies. Some researchers contend that lower SES African American women are at a higher risk for becoming obese than are higher SES African American women (O’Neill, 2003) while others have found no relationship between the prevalence of eating disorders and obesity and socioeconomic status in African Americans (Swanson et al., 2011; Zhang & Wang, 2004). With regard to poverty and obesity, some researchers have argued that women who struggle with poverty may suffer from malnutrition or from food diets high in fats and sugars (Dounchis et al., 2001; Paul, 2003). In fact, Kumanyika and Grier (2006) suggested that research typically shows low-income children typically live in areas that have a high concentration of fast food unhealthy restaurants than in predominately White and higher class neighborhoods. These low-income areas may present additional barriers including unsafe and often dangerous streets and neighborhoods that provide inadequate areas for children to play and exercise.
Given that African American families’ SES is likely to be disproportionately lower than European American families (Dounchis et al., 2001; Paul, 2003), and that obesity is a problem among African American youth, it is important to consider that children who come from working or lower class African American families may be at risk for becoming overweight or obese. In contrast, although African American children from middle-class families may be protected from poverty and malnutrition (Day-Vines et al., 2003), they still may experience eating disorder attitudes and behaviors that are related to majority cultural values. Indeed, Robinson et al. (2001) found that higher SES was associated with more dieting behaviors, weight preoccupation, and thinner desired body shape in a sample of African American elementary schoolchildren. Given the inconsistencies and limited empirical findings in this area, counselors should be aware of the potential implications of SES on the presentation of eating behaviors and attitudes in African American youth.
Family Perceptions of Food, Weight, and Body Image
Given the strong emphasis placed on family (including extended family members) in African American culture (Kempa & Thomas, 2000), how family members influence their children with respect to body satisfaction/body acceptance or food behaviors may impact whether or not African American youth are at risk for developing eating disorder symptoms. Some research has shown that family influences play a large role in how African American youth, particularly females, view their bodies (Franko & George, 2010). For example, when selecting an ideal body size, Black girls reported a greater influence by immediate family members (mother/grandmother, sisters, brothers) while White girls were more influenced by their peer group’s selection of an ideal size. In addition, African American mothers have been found to convey their positive weight-related attitudes to their daughters (George & Franko, 2010). Then, again, African American parents’ acceptance of larger body ideals and overweight status in their children could prevent them from recognizing the presentation of eating pathology in their children. For example, Elliot, Tanosky-Kraff, and Mirza (2013) investigated parent reports of binge eating among an obese group of diverse adolescents and found that African American parents were less likely to report observing binge eating in their children when compared to White and Hispanic parents (Elliot et al., 2013). Similarly, Dalton et al. (2007) investigated African American parents’ awareness of their children’s weight concerns and found that African American parents were not consistently aware of their daughter’s weight concerns and weight control behaviors. Perhaps African American parents’ cultural acceptance of heavier body ideals and overweight status in their children may prevent them from acknowledging weight-related concerns and unhealthy weight behaviors in their children (Dalton et al., 2007; Elliot et al., 2013). Given their role in African American families, parents and/or caregivers may be well poised to intervene in the development of children’s unhealthy weight concerns/behaviors if their awareness of these behaviors is raised (Dalton et al., 2007).
Weight-Related Teasing
The majority of research on weight-related teasing has been conducted on White samples. Findings from these studies have revealed that weight-related teasing by peers has been identified as a risk factor for binge eating and other weight control behaviors in females (Neumark-Sztainer et al., 2007; Suisman et al., 2008). For African American youth, it appears that weight-related teasing by parents seems to have a broader influence on girls’ emotional and binge eating compared to weight-teasing by peers, but is not associated with other unhealthy weight control methods (e.g., dieting, skipping meals). These results could be attributed to the fact that African American youth, overall, tend to engage in more binge eating behaviors than restrictive behaviors (Cassidy et al., 2012; Johnson et al., 2002; Swanson et al., 2011; Taylor et al., 2007). Most importantly, these results suggest that family members’ negative commentary can be largely influential in whether or not African American children engage in unhealthy eating practices.
Externalizing Behaviors
Compared to the general population, African Americans are disproportionally exposed to a number of stressors (e.g., neighborhood violence, blocked opportunity structures, institutional racism) that can lead to both internalizing (e.g., depression) and externalizing (e.g., physical altercations) behaviors. In fact, researchers have found that increased experiences of daily and racial stressors in life have been linked to increased levels of both depression and physical violence, particularly among African American males who are transitioning from adolescence into adulthood (Estrada Martinez et al., 2012). With respect to the eating disorders literature, externalizing behaviors such as aggression, behavioral impulsivity, and conduct problems have been linked to bulimia type symptoms (Bodell et al., 2012). Since African American youth may experience additional societal stressors unique to their socialization experiences which could, in turn, lead to possible externalizing behaviors, it’s possible that externalizing behaviors may serve as a risk factor for the development of eating disorder symptoms in this population. There is some research that suggests parental reports of African American girls’ impulsivity were found to be associated with child reports of bulimic symptoms (binge eating) 9 years later—these results suggest that behavioral impulsivity in early childhood may potentially predict the presence of future eating disorder symptomatology in African American girls (Bodell et al., 2012).
Clinical Treatment Interventions
Multiple contextual factors such as acculturation, institutionalized racism, and classism are potential realities in the lives of many African American youth and may serve as risk factors to the development of eating disorder symptoms in this population. Yet, traditional risk factors such as body dissatisfaction are often used to evaluate the presence of eating disorder symptoms in all children (Grabe & Hyde, 2006; Kempa & Thomas, 2000).
A clinician’s understanding of the sociocultural background in eating disorders presentation and help-seeking behaviors of African American could improve the culturally competent care provided to this population, particularly since African Americans are least likely to use mental health services when compared to all other racial and ethnic groups in the USA (Franko et al., 2007; Sanders-Thompson, Bazile, & Akbar, 2004; Whaley, 2001). Specific recommendations can be made for assessing risk factors in African American youth and for providing culturally competent counseling when working with African American youth who present with concerns regarding body appearance, weight, or eating attitudes and behaviors. Clinicians should be aware that there are many potential barriers to mental health care for African Americans based on their sociopolitical histories and cultural beliefs. For example, research suggests that people of color may underutilize treatment services for eating disorders because of lack of financial resources or insurance, strong distrust of the mental health system, fears that others may not be able to help, lack of awareness of resources, and feelings of shame and stigmatization (Alegria et al., 2007; George & Franko, 2006; Kempa & Thomas, 2000; Nicdao et al., 2007; Smart, 2010b; Sue & Sue, 2008). When working with African American youth and their families, clinicians should address issues of trust and potential fears early on in the counseling session. Furthermore, the provision of psychoeducational workshops in local schools, community centers, and religious organizations may be a culturally appropriate method of providing access to useful resources for African American families (Story et al., 2003).
School counselors and community therapists may want to use a more inclusive assessment system when working with African American youth who struggle with eating, weight, and body image concerns. Since researchers have shown that some traditional eating disorder measures (e.g., Eating Attitudes Test-26 [EAT-26]) may not assess the same constructs in people of color (Kelly et al., 2011), additional data sources including use of acculturation and racial or ethnic identity measures could provide a more comprehensive assessment system when working with African American youth. Consequently, use of a comprehensive assessment system could also improve rates of eating disorder diagnosis, treatment, and referrals among African American youth.
Understanding how a client’s level of a cculturation to his or her traditional culture or the dominant culture influences his or her beliefs regarding food and physical appearance is critical. Therefore, assessing levels of acculturation and enculturation with clients can provide useful information on how and why clients present with weight concerns. Potential questions to pose with clients who have experienced the acculturation process could include migration status, generational status, rationale for coming to the USA, language acquisition, duration of time spent in the USA, lack of family presence, and ethnicity of social networks. Use of a cultural genogram (Hardy & Laszloffy, 1995) could be an effective tool in eliciting information about the process clients and their families have gone through in coping with competing cultural demands involved in the acculturation process. In addition, a cultural genogram could potentially help clients uncover the messages related to the role of food, eating behaviors and attitudes, body image, and overall appearance that have been passed down in the family. Some questions could include what kinds of messages regarding beauty and appearance were you raised with? What makes you aware of your body? How do you think being African American affects how you view beauty and your appearance?
In addition to assessing levels of acculturation , clinicians should assess the degree to which African American youth have internalized racial oppression (Kempa & Thomas, 2000; Talleyrand, 2006, 2010). More specifically, helping clients identify the oppressive forces in their lives, helping them to accept and affirm their racial group membership, and to develop healthy body image could assist with how they view themselves as racial beings. As mentioned earlier, when working with bi-racial and/or multiracial clients it is important to assess the strength of their identification with each of their racial or ethnic groups since this may affect their beliefs regarding appearance.
Clinicians should consider referring to stress and coping models that address issues pertaining to African American youth to assist them in working with their clients. Given that African Americans are disproportionally exposed to a number of stressors (e.g., neighborhood violence, blocked opportunity structures, institutional racism) that can lead to both internalizing (e.g., depression) and externalizing (e.g., physical altercations) behaviors, exploring the coping strategies African American youth use to respond to these stressors may be a useful tool in the counseling process. For example, assessing the relationship between African American youth’s appraisal of racial stressors and the enactment of subsequent coping strategies, particularly overeating, may be useful in evaluating how they manage their racial stress and in evaluating whether negative physical health outcomes (e.g., obesity) are related to the use of particular coping strategies. Use of formal measures such as the Schedule of Racist Events (SRE; Landrine & Klonoff, 1996) or the Index of Race-Related Stress (IRRS; Utsey & Ponterotto, 1996) may help counselors assess the types and frequency of race-related stress experienced by African Americans. Informally, clinicians can ask clients to list the most salient stressors in their lives and then have them describe the types of coping mechanisms (e.g., active or passive) they use when they encounter these stressors.
In addition to assessing the sociocultural factors outlined above, specific recommendations can be made regarding counseling therapies and modalities that may be effective when working with American youth who present with eating disorder symptoms: For example, cognitive behavioral therapy (CBT) is an evidence-based approach that has been found to be effective in the treatment of eating disorders; in particular, in treating clients who struggle with bulimia (American Psychiatric Association, 2006; Smart, 2010a, 2010b). The use of CBT could be effective when working with African American youth because of its emphasis on a solution-focused, time limited approach, educational and practical focus, collaborative action, and lack of emphasis on the past or family. These components of CBT may be well accepted among groups that have been underrepresented and may distrust the mental health care system (Sue & Sue, 2008; Smart, 2010a, 2010b). Nonetheless, it should be noted that counselors still may need to adapt this approach to include an exploration of the contextual factors and cultural values that are relevant in understanding how a client perceives her problem (Sue & Sue, 2008; Smart, 2010a, 2010b). For example, body satisfaction for African American youth may include an evaluation of a client’s facial features (skin color, nose) and hair (Grabe & Hyde, 2006; Mintz & Kashubeck, 1999; Smart, 2010b) in addition to body parts.
Interpersonal therapy (IPT) is another evidence-based therapy that can be used with clients in individual or group settings (APA, 2006). IPT is a time limited and semi-structured form of therapy that focuses on assisting clients to identify and cope with the interpersonal difficulties they face in their lives rather than focus specifically on their disordered eating thoughts and behaviors (Choate, 2010). The assumption in IPT is that women may use disordered eating behaviors to cope with the relational difficulties they may be experiencing including lack of social support, conflict with peers, and family difficulties (Choate, 2010). Given the fact that African American youth may struggle with multiple life stressors (e.g., acculturation processes, role conflict, experiences of racism, racial identity) that could impact their interpersonal relationships, the use of IPT could provide the contextual framework necessary when working with youth who present with disordered eating attitudes and behaviors. Also, unlike CBT, IPT does not focus on internalization of the thin ideal, which is a behavior that is rarely endorsed by African Americans (Kelly et al., 2011).
Group counseling may be an effective mode of service delivery when working with African American youth because of the nature of the experience—group counseling calls for close relationships among group members and a sense of community (Williams, Frame & Green, 1999). The emphasis on close relationships and community is consistent with the collectivistic values embedded in African American culture (Green, 1994; Kempa & Thomas, 2000). Further, use of group therapy versus traditional individual therapies with African American youth may feel less threatening given potential barriers (e.g., distrust of the mental health system) related to accessing mental health services among this population (George & Franko, 2010; Williams et al., 1999). Finally, the empowering and egalitarian nature of the group counseling process also may be appealing to African American youth who may face several forms of oppression on a daily basis (Coker, Meyer, Smith, & Price, 2010).
Family therapy has been considered another effective form of therapy for clients struggling with eating disorders since it deals with family relational problems that may contribute to the development of an eating disorder (APA, 2006) and is particularly helpful for adolescent clients (Read & Hurst, 2013). Given the strong value placed on family (including extended family members) in African American culture and the influence of family members on children’s perceptions of their appearance and food behaviors (Olvera et al., 2013), family therapy may be an effective and culturally relevant form of therapy when working with African American clients who present with eating and body concerns (Kempa & Thomas, 2000). However, it is imperative that family members are educated about the general risk factors associated with the development of eating disorders since lack of awareness could lead to lack of recognition of eating pathology in their children. Nonetheless, parents and/or caregivers may be well poised to intervene in the development of children’s unhealthy weight concerns/behaviors if their awareness of these behaviors is raised (Dalton et al., 2007; Elliot et al., 2013).
Motivational interviewing techniques may also be another effective form of therapy when working with African American youth who present with eating disorder symptoms. Motivational interviewing is an empathetic style of counseling that consists of working collaboratively with clients to explore and reduce barriers to behavior change (Seligman, 2004). Motivational interviewing interventions include techniques that extend beyond weight-related concerns and have been found to be effective with obesity prevention programs (Lydecker, Cotter, Gow, Kelly, & Mazzeo, 2013). Use of motivational interviewing techniques that extend beyond weight-related concerns may be useful for African American youth given the fact that they may f ocus less on weight concerns.
Conclusion
Historically, eating disorders were known only to occur among White female adolescents, yet more recently, have been found to affect all racial and ethnic groups (Franko et al., 2007; George & Franko, 2010; Grabe & Hyde, 2006; Smolak & Striegel-Moore, 2001). The existing (albeit limited) research examining eating disorders in African American youth suggests that African American youth, primarily girls, engage in lower levels of body dissatisfaction and restrictive eating behaviors when compared to their White counterparts. However, African American youth (both boys and girls) tend to engage in equal or greater rates of binge eating behaviors. Further, the increasing number of African American youth diagnosed with obesity and overweight status along with the relationship between obesity and disordered eating behaviors and body dissatisfaction highlights the possibility that more African American youth will present with eating disorder symptoms in the future. Therefore, clinicians should not assume that African American youth, overall, would be protected from developing disordered eating symptoms. Furthermore, how African American youth present their eating disorder symptoms may vary from traditional clinical presentations of eating disorder symptomatology. That is, sociocultural factors (e.g., institutionalized racism, racial identity, cultural values) should be included when assessing how African American youth manifest their eating disorder symptoms. Use of culturally appropriate obesity prevention programs could also be effective for this population since obesity rates are increasing in the African American population (Story et al., 2003). Finally, future research should employ the use of both quantitative and qualitative methods of evaluating body appearance and eating attitudes and behaviors in African American youth since most traditional assessments have been normed primarily on White samples and may not provide a comprehensive picture of the complex experiences of African American youth.
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Talleyrand, R.M. (2016). Eating Disorders. In: Breland-Noble, A., Al-Mateen, C., Singh, N. (eds) Handbook of Mental Health in African American Youth. Springer Series on Child and Family Studies. Springer, Cham. https://doi.org/10.1007/978-3-319-25501-9_12
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