Clin Child Fam Psychol Rev (2010) 13:213–230
DOI 10.1007/s10567-010-0072-1
The Relation Between Eating- and Weight-Related Disturbances
and Depression in Adolescence: A Review
Jennine S. Rawana • Ashley S. Morgan •
Hien Nguyen • Stephanie G. Craig
Published online: 15 July 2010
Ó Springer Science+Business Media, LLC 2010
Abstract Depression often emerges during adolescence
and persists into adulthood. Thus, it is critical to study risk
factors that contribute to the development of depression in
adolescence. One set of risk factors that has been recently
studied in adolescent depression research is eating- and
weight-related disturbances (EWRDs). EWRDs encompass
negative cognitions related to one’s body or physical
appearance, negative attitudes toward eating, and unheal-
thy weight control behaviors. However, there have been no
comprehensive reviews of EWRDs and depression research
that are contextualized within developmental frameworks
of adolescent depression. Thus, this review will summarize
research findings on the relation between EWRDs and
depression in adolescence using a cognitive vulnerability
developmental framework. First, a brief overview of epi-
demiological findings on depression is provided in order to
highlight the importance of examining depression in ado-
lescence. Second, a cognitive vulnerability developmental
framework that can be used to conceptualize depression in
adolescence is described. Next, theories and findings on
EWRDs and depression in adolescence are summarized
within this framework. Research limitations and sugges-
tions for future research are provided. Finally, implications
of this review related to the assessment, intervention, and
prevention of depression in adolescence are provided.
Keywords Adolescent development
Depression

Risk factors
Eating- and weight-related behavior

Eating- and weight-related cognitions
J. S. Rawana (&)
A. S. Morgan
H. Nguyen
S. G. Craig
Department of Psychology, York University, BSB 101,
4700 Keele Street, Toronto, ON M3J 1P3, Canada
e-mail: rawana@yorku.ca
Depression is a common mental health issue facing chil-
dren, adolescents, and adults and has numerous health,
economic, and quality of life implications. Depression
often emerges during adolescence (ages 12–18; Arnett
1999; Kessler et al. 2001) and recurs or persists into
adulthood (Lewinsohn et al. 2003). The consequences of
depression during adolescence include an increased risk for
various maladaptive behaviors, such as substance abuse
and suicidal behavior, as well as interpersonal, academic,
and psychosocial problems (Birmaher et al. 1998; Meri-
kangas and Angst 1995; Nolen-Hoeksema et al. 1992).
Thus, adolescence represents a critical time to study risk
factors that contribute to the development of depression.
One set of risk factors that has been recently studied in
adolescent depression research is eating- and weight-rela-
ted disturbances (EWRDs; e.g., Stice and Bearman 2001).
EWRDs are defined as those negative or maladaptive
cognitions, attitudes, and behaviors directly or indirectly
related to eating and weight. Maladaptive eating cognitions
include negative eating attitudes (e.g., believing that pop-
ularity with peers is related to how much one weighs and
that peers prefer to date thin people), body dissatisfaction
(e.g., preference to be a smaller size), and focusing on a
thin or muscular ideal body type. Maladaptive eating
behaviors include dietary restraint and overeating (e.g.,
having the desire to eat when feeling lonely), bingeing, and
use of substances to control one’s weight (e.g., diet pills,
steroids, cigarette smoking; Crow et al. 2008). EWRDs are
generally conceptualized as less severe dysfunctional eat-
ing cognitions, attitudes, and behaviors compared to clin-
ical symptoms of eating disorders (e.g., severe restriction
of caloric intake as in anorexia nervosa and bingeing and
purging as in bulimia nervosa). Although there is growing
evidence linking EWRDs and depression in adolescence,
there have been no comprehensive reviews of this relation
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that contextualize findings within empirically supported
developmental frameworks used to understand depression
in adolescence. One key theory used to understand
depression in adolescence is the cognitive vulnerability
framework (Abela and Hankin 2008). Given that depres-
sion often emerges during adolescence, a review of the
relation between EWRDs and depression in adolescence
using a developmentally based cognitive vulnerability
framework represents a valuable contribution to the ado-
lescent depression literature.
Thus, the purpose of the current review was to identify
studies that have investigated the relation between EWRDs
and depression in adolescence and contextualize the find-
ings within a comprehensive developmental model of
adolescent depression. The organization of the review is as
follows. First, the importance of examining depression in
adolescence is underscored by means of a brief overview of
epidemiological findings. Second, a developmentally based
cognitive vulnerability framework that can be used to
conceptualize depression in adolescence is described. After
describing the search strategy to identify studies examining
the relation between depression and EWRDs, theories and
findings on the relation between EWRDs and depression
are presented and are then integrated into a novel etio-
logical model of adolescent depression. Research limita-
tions and directions for future research are also presented.
Lastly, given that major depression is the third most dis-
abling condition in the world and the second most in the
developed world (World Health Organization 2008),
implications for assessment, intervention, and prevention
initiatives related to adolescent depression are provided.
Adolescent Depression
Epidemiological studies suggest that depression often
emerges in adolescence (Lewinsohn et al. 2003). For
example, lifetime prevalence of depression increases dra-
matically from 1% under age 12 to roughly 17–25% by the
end of adolescence, and the greatest surge of newly
emergent cases occurs between the ages of 15 and 18 years
(Hankin et al. 1998; Kessler et al. 2001). Furthermore,
studies suggest that between 20 and 50% of adolescents
reported symptoms of depression (Kessler et al. 2001). A
recent community-based study found the prevalence rate of
depression to be 6.5% among adolescents (Afifi et al.
2005).
Epidemiological studies also highlight gender differ-
ences in depression rates that emerge in adolescence and
continue into adulthood. Depression rates are two to three
times higher among females than males in both adolescent
and adult populations (Hankin et al. 2008). Studies report
that symptoms of depression are endorsed by 20–35% of
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Clin Child Fam Psychol Rev (2010) 13:213–230
adolescent males and 25–55% of adolescent females
(Hankin 2006; Offord et al. 1987). Developmentally, gen-
der differences have been shown to emerge around 12 or
13 years of age (Hyde et al. 2008). Much of the research in
the depression literature has underscored gender differ-
ences in the rates of depression, but less research has
examined the factors that contribute to the emergence of
gender differences in adolescence. Pubertal development
and associated EWRDs (e.g., weight and body image
changes) have been proposed as possible factors (Hyde
et al. 2008). Thus, there may be underlying developmental
processes occurring during adolescence that are key to
understanding gender differences in depression. The cog-
nitive vulnerability framework can be used to understand
the developmental processes that may contribute to the
emergence of depression in adolescence.
Cognitive Vulnerability Developmental Framework
Within the depression literature, the cognitive vulnerability
framework has been widely supported by researchers and
clinicians as a comprehensive theory to understand the
development of depression across the life span. The
majority of this support stems from research using adult
samples, although recently, researchers have applied this
theory to understand depression in adolescence (Abela and
Hankin 2008). Cognitively based models of depression
define cognitive vulnerabilities as internal and stable cog-
nitive characteristics of an individual that may arise from
childhood interpersonal experiences, genetic and biological
vulnerabilities, and negative life events (Abela and Hankin
2008). Cognitive vulnerabilities include thought patterns,
such as hopelessness, depressogenic schemas (e.g., worth-
lessness), and negative response styles (e.g., rumination;
Abela and Hankin 2008). According to the cognitive vul-
nerability framework, when individuals predisposed to
maladaptive cognitions experience a negative life event,
there is an increased chance of developing depression
(Abela and Hankin 2008). In other words, experiencing a
negative event may trigger specific cognitive vulnerabili-
ties and a pattern of self-referent information processing,
thereby leading to depression. The cognitive vulnerability
framework also allows for the individual’s perception of
the negative event to play a substantial role in the devel-
opment of depression.
This framework is also useful for examining the
relation between EWRDs and depression as there appears
to be an underlying cognitive component in both of these
domains (e.g., negative body image). Furthermore, the
cognitive vulnerability framework provides a more com-
plex and comprehensive understanding of the important
developmental tasks characteristic of adolescence (e.g., the
Clin Child Fam Psychol Rev (2010) 13:213–230
role of puberty) and resulting cognitive distortions associ-
ated with the negotiation of such tasks (e.g., poor body
image because of weight gain associated with puberty).
Indeed, some adolescents may be particularly at risk for
depression as a result of their still-developing cognitive
styles (Abela and Hankin 2008). It is important to note that
theories of depression generally neglect EWRDs as risk
factors, although there is growing evidence supporting their
role in the emergence and maintenance of depressive
symptoms. In order to document this evidence, a compre-
hensive search of the research literature was undertaken for
the purpose of this review.
Search Methodology
An initial search was conducted in PsycINFO, MedLine,
the Cochrane Review, and Social Science Abstracts using
the following search strategy: ‘‘Body image disturbances
OR body image AND depressi* NOT eating disorders;’’
‘‘Eating attributes OR body image OR body dissatisfaction
AND major depression OR depressive symptoms AND
prospective study;’’ ‘‘eating behavi* OR body image OR
body dissatisfaction AND major depression OR depressive
symptoms;’’ ‘‘eating disorder symptomology OR eating
disturbances OR dysfunctional eating attitudes AND
behavioral problems OR behavior*.’’ The keywords used
were also verified for relevance against acceptable studies
that were included in the review. The search strategy
included literature cited from 1989 to 2010. A secondary
manual search strategy was also employed whereby rele-
vant references from the selected articles were identified
and located. Additionally, a search was conducted to
identify relevant studies that had cited the selected articles.
All studies included in the review component of the current
paper were corroborated by two reviewers (i.e., the first and
second authors). Efforts were made to locate unpublished
information gathered during the search via dissertation
abstracts if the study consisted of a longitudinal design.
With respect to exclusion criteria, no populations were
excluded from the search based on age, ethnicity, or other
demographic characteristics. Studies investigating the
comorbidity between clinically diagnosed eating disorders
and depression were excluded so as to keep the focus of the
present review on subclinical EWRDs.
Table 1 lists the identified studies that examined EW-
RDs and depression. All studies initially sampled adoles-
cents; however, due to the variety of follow-up times used
in several of the longitudinal studies, some of the samples
consisted of young adults. Studies are described in terms of
citation (authors and publication year), study design
(community vs. school, cross-sectional vs. longitudinal),
sample characteristics (sample size, percentage of females,
215
mean age, grades for school samples), measures employed,
and a brief summary of results.
Theories and Findings on the Relation Between EWRDs
and Depression
In order to present the research in an organized manner,
research findings are contextualized within key theories
used by researchers to explain the relationship between
EWRDs and depression, including the dual pathway model
of bulimic pathology, the gender additive model, and the
objectified body consciousness (OBC) theory. Where
applicable, research findings are also contextualized within
the cognitive vulnerability developmental framework.
One of the most empirically supported theories was the
dual pathway model of bulimic pathology that posits that
elevated body mass, body dissatisfaction, and dieting
contribute to depression among adolescent females, which
in turn promote the development of bulimic behaviors (e.g.,
purging; Stice et al. 1996). Earlier research supporting this
theory includes a study by Rierdan et al. (1989) that
identified body image as a predictor of the persistence of
depression among early adolescent females. In this study,
the relation between body image and depression differed
for persistently and transiently depressed females. The
authors concluded that the role of body image was a
potential distinguishing feature in differentiating adoles-
cent females for whom depression will be a persistent
disorder from adolescent females for whom depression will
be time limited (Rierdan et al. 1989). In another earlier
study by Allgood-Merten et al. (1990), it was found that
having low self-esteem was an antecedent to becoming
depressed. Furthermore, body image was found to be an
important correlate of depression; however, the shared
variance between depression and body image variables was
eliminated when self-esteem was controlled for in the
analysis.
More recently, Stice et al. (2000) conducted a longitu-
dinal study using a large, ethnically diverse, school sample
with female adolescents, and found that elevated body
dissatisfaction, dietary restraint, and bulimic symptoms at
study entry predicted the onset of subsequent depression.
Additionally, a longitudinal study by Stice and Bearman
(2001) found that pressure to be thin, thin-ideal internali-
zation, body dissatisfaction, dieting, and bulimic symp-
toms, but not body mass index (BMI), predicted subsequent
increases in depression. Given the prospective nature of
this study, the results suggest that body image and EWRDs
are not simply concomitants or consequences of depression
(Stice and Bearman 2001). Results from Holsen et al.’s
(2001) longitudinal study are consistent with these find-
ings, such that adolescent females on average reported
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Table 1 Chronological presentation of studies that examined the relation between eating- and weight-related disturbances and depression
Citation Study design Sample Measures Results

Rierdan et al. Longitudinal n = 505 females BDI, Short Form Persistently depressed individuals
(1989) Follow-up: 6 months Mean age = 13.17 Body Cathexis Scale have poorer body images than
those who are transiently
School sample Grades 6–9 Body Experience Scale
depressed or non-depressed
Allgood- Longitudinal n = 664 males and CES-D Anxiety, low self-esteem, and
Merten Follow-up: 1 month females Major Life Events Inventory stressful recent events predicted
et al. (1990) Mean age = 16.14 depression symptoms
School sample RSES
Grades 9–12 Body image important correlate of
State-Trait Anxiety Inventory
depression in adolescence, but
Personal Attributes Qx, SV shared variance eliminated when
Self-Consciousness Scale self-esteem controlled
Offer Self-Image Qx (Body Image Females [ males for depressive
subscale) symptoms, self-consciousness,
Body Parts Satisfaction Scale feminine attributes, recent stressful
events, and negative body image
Body-Self Relation Qx and self-esteem
Graber et al. Longitudinal n = 116 females CES-D Eating problems in early and
(1994) Follow-up: 2 and 8 years Mean age = 14.31 Achenbach Youth Self-Report mid-adolescence were associated
with earlier pubertal maturation,
School sample Grades 7–9 EAT
higher body fat, concurrent
Weight/body fat/age at menarche psychopathology, subsequent
Satisfaction with Body Parts Scale eating problems, and depressive
SIQYA (Body Image, Emotional affect in young adulthood
Tone, and Family Relations
subscales)
EDI (selected subscales)
Wichstrøm Cross-sectional n = 10,839 males and JHSC 14- to 20-year-olds:
(1999) School sample females PDS females [ males by 0.5 SD on
Age range = 12–20 depressed mood; difference
BMI (self-report)
emerged between 13 and 14 years
Grades 7–12 Body Areas Satisfaction Scale of age
SPPA (Physical Appearance Early and late puberty associated
subscale) with depressed mood compared
with adolescents who were
on-time
Increase in females’ body
dissatisfaction coincided with
elevated depressed mood
Body dissatisfaction affected
depressed mood through decreased
self-worth
Thompson Cross-sectional n = 3,630 females Eating disturbances and attempted Adolescents who report engaging in
et al. (1999) School sample Mean age = 14.9 suicide measures (both eating disturbance behaviors are
developed for study) more likely to report aggressive
Grades 6–12
behaviors
Both eating disturbance and
aggressive behaviors predict
suicidal behaviors and drug use in
adolescent females
Those reporting eating disturbance
behaviors were three times more
likely to report suicidal gestures
than those not reporting eating
disturbance behaviors

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Table 1 continued
Citation Study design Sample Measures Results

Stice et al. Longitudinal n = 1,124 females CES-D Initial elevations in body

(2000) Follow-up: 1, 2, and Mean age = 14.7 SCID dissatisfaction, dietary restraint,
3 years and bulimic symptoms, but not
BMI
body mass, predicted subsequent
School sample EDI (selected subscales) onset of major depression when
Restraint Scale controlling for initial depressive
symptoms
Holsen et al. Longitudinal n = 645 (49% female) 4-item body image scale Body image and depressed mood
(2001) Follow-up: 2 and 5 years Mean age = 13 7-item depressed mood scale were significantly correlated at all
measurement occasions;
School sample
correlations were nearly as strong
for males as for females
Body image predicted changes in
depressed mood longitudinally
No evidence for a longitudinal
causal effect of depressed mood
upon body image found
Stice and Longitudinal n = 231 females BMI (self-report) Initial elevations in perceived
Bearman Follow-up: Mean age = 14.9 Perceived Sociocultural Pressure pressure, thin-ideal internalization,
(2001) Scale body dissatisfaction, dieting, and
10 and 20 months Grades 9–10
bulimic symptoms, but not body
School sample Ideal Body Stereotype
mass, predicted subsequent
Scale—Revised
increases in depressive symptoms
Satisfaction and Dissatisfaction
Provides support that body image
with Body Parts Scale
and eating disturbances contribute
Dutch Restrained Eating Scale to elevated depression in females,
EDE beyond other risk factors (e.g.,
Emotionality Scale social support and emotionality)
Burns Depression Checklist
Siegel (2002) Longitudinal n = 877 (46% female) PDS Consistent negative body image
Follow-up: 1 to 2.5 years Age range = 12–17 BMI (self-report) associated with an increase in
depression
Community sample 4-item body image scale
Change in body image predicted
RSES
depression among females
CDI
Change in body parts satisfaction
predicted change in depressed
mood independently of global
assessments about the self
Ohring et al. Longitudinal n = 120 females BMI Body dissatisfaction and depressive
(2002) Follow-up: 2 and 8 years Mean age = 14.31 SIQYA (Body Image and symptoms were linked over time
School sample Grades 7–10 Emotional Tone subscales) Those with recurrent body
Satisfaction with Body Parts Scale dissatisfaction had elevated
depressive symptoms in young
EAT
adulthood
CES-D
Johnson et al. Longitudinal n = 717 (51% female) DISC (Parent and youth versions) Specific problems with eating or
(2002a) Follow-up: 2 and 8 years and their mothers Personality Diagnostic Qx weight during adolescence are
Mean age = 13.8 associated with an increased risk
Community sample
for physical and mental disorders
during early adulthood
Fasting, frequently exercising to lose
weight, self-induced vomiting, and
strict dieting during adolescence
were associated with health
problems during early adulthood
after controlling for relevant
demographic variables and other
covariates

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Table 1 continued
Citation Study design Sample Measures Results

Eating alone to conceal unusual

eating behavior, eating a large
amount of food, and frequent
fluctuations in weight during
adolescence were associated with
early adulthood health problems
Johnson et al. Longitudinal n = 726 adolescents DISC (Parent and youth versions) Depressive disorders in early
(2002b) Follow-up: 2 and 8 years (51% female) and Personality disorders assessed adolescence independently
their mothers associated with increased risk for
Community sample with various items based on
Mean age = 13.8 the development of six types of
established measures eating and weight problems during
middle adolescence or early
adulthood
Keery et al. Cross-sectional n = 325 females CES-D Internalization and comparing one’s
(2004) School sample Mean age = 12.6 RSES physical appearance to others fully
mediated the relation between
Grades 6–8 Quetlet’s Index of Fatness (BMI)
parental influence and body
Perception of Teasing Scale dissatisfaction and partially
Perceived Preoccupation with mediated the relation between peer
Weight and Dieting Scale influence and body dissatisfaction
Family/Peer/Media Influence Internalization and comparison
Parental Involvement Scale partially mediated the relation
between media influence and body
McKnight Risk Factor Survey dissatisfaction
Interest Scale
Perceived Sociocultural Pressure
Scale
SIAQ-A
Physical Appearance Comparison
Scale
Social Comparison Qx
EDI (selected subscales)
SIQYA (Body Image subscale)
Paxton et al. Longitudinal n = 806 early Depressive Mood Scale, 6-items Body dissatisfaction was a
(2006) Follow-up: 5 years adolescents (55% RSES, SV prospective risk factor for
female) depressive mood and low self-
School sample BMI (standardized measurement)
Mean age = 12.75 esteem over five years in both
Body Shape Satisfaction Scale females and males
n = 1,710 mid-
adolescents (55% Body dissatisfaction predicted
female) depressive mood and low self-
esteem in early but not mid-
Mean age = 15.85
adolescent females, and mid- but
not early adolescent males
Crow et al. Longitudinal n = 2,516 (55% JHSC Young women’s extreme weight
(2008) Follow-up: 5 years female) BMI control behaviors were predictive
Mean ages = 17.2 and of suicidal ideation and suicide
School sample Body Shape Satisfaction Scale
20.4 attempts independent of depressive
Suicidal thoughts and behaviors symptoms
Unhealthy/Extreme weight control Body dissatisfaction, unhealthy
behaviors weight control behaviors, and
weight status were not predictive
of suicidal behavior in males or
females

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Table 1 continued
Citation Study design Sample Measures Results

Presnell et al. Longitudinal n = 496 females Eating Disorder Diagnostic Depressive symptoms prospectively
(2009) Follow-up: annually for Mean age = 13.5 Interview predicted increases in bulimic
7 years K-SADS symptoms and bulimic symptoms
Grades not specified
also predicted future increases in
School sample
depression
Bulimic and depressive symptoms
are reciprocally related with each
increasing the risk for the other
BMI body mass index, BDI Beck Depression Inventory, CES-D Center for Epidemiologic Studies—Depression Scale, CDI Children’s Depression
Inventory, DISC Diagnostic Interview Schedule for Children, EAT Eating Attitudes Test, EDE Eating Disorder Examination Questionnaire, EDI
Eating Disorders Inventory, JHSC Johns Hopkins Symptom Checklist, K-SADS Schedule for Affective Disorders and Schizophrenia for School-
Age Children, PDS Pubertal Development Scale, Qx questionnaire, RSES Rosenberg Self-Esteem Scale, SCID Structured Clinical Interview for
DSM-III-R, SD standard deviation, SIAQ-A Sociocultural Internalization of Appearance Questionnaire—Adolescents, SIQYA Self-Image
Questionnaire for Young Adolescents, SPPA Self-Perception Profile for Adolescents, SV short version

higher levels of depression and more negative body image
than adolescent males at all ages. Also consistent with the
Stice et al. (2000) and Stice and Bearman (2001) findings,
body image and depressed mood were significantly corre-
lated at all measurement occasions. Surprisingly, the
association was nearly as strong for adolescent males as for
adolescent females. The results of this study suggest that
body image is a significant predictor of changes in
depressed mood over time (Holsen et al. 2001). Further-
more, Ohring et al. (2002) found that recurrent body dis-
satisfaction during adolescence was associated with
elevated depression in young adulthood compared with
girls who maintained positive body images during adoles-
cence. These results suggest that experiencing body dis-
satisfaction during adolescence has consequences for
psychological well-being in young adulthood. Keery et al.
(2004) conducted a study to examine the processes that
may underlie body dissatisfaction. Path analyses indicated
that internalization and appearance comparison fully
mediated the relationship between parental influence and
body dissatisfaction. Body dissatisfaction was also related
to dietary restriction, bulimia, and psychological func-
tioning as indicated by self-esteem and depression (Keery
et al. 2004). Interestingly, a recent longitudinal study by
Presnell et al. (2009) examined the reciprocal relations
between depressive and bulimic symptoms among adoles-
cent females over 7 years. Results from hierarchical linear
modeling indicated that depression prospectively predicted
future increases in bulimic symptoms and that bulimic
symptoms also predicted future increases in depression.
Although the majority of research presented in this
review highlights the prospective relation between EWRDs
and depression, some studies have reported findings that
depression may precede the development of EWRDs
(Presnell et al. 2009). Specifically, Johnson et al. (2002a, b)
have found that depression during early adolescence was
independently associated with increased risk for the
development of six types of eating and weight problems
during middle adolescence or early adulthood. The six
types of eating and weight problems included (1) adher-
ence to a strict diet to lose weight, (2) eating alone to
conceal unusual eating behavior, (3) fasting for 24 h or
longer to lose weight, (4) recurrent fluctuations of 10 lbs or
more in body weight, (5) self-induced vomiting, and (6)
use of medication to lose weight. Results from this study
also indicated that disruptive behavioral disorders during
early adolescence were independently associated with risk
for recurrent fluctuations of 10 lb or more in body weight
during middle adolescence and early adulthood.
In sum, the findings reviewed tend to support the dual
pathway model of bulimic pathology. In terms of
explaining the relation between EWRDs and depression,
this model adds an additional outcome, namely bulimic
symptoms, and posits the existence of a cyclical process
involving depression and bulimic behaviors. However,
despite this model’s empirical support, it may be too spe-
cific in its focus in terms of explaining the relation between
EWRDs and depression because it excludes other types of
EWRDs. Other less researched theories include the gender
additive model (Stice and Bearman 2001) and the OBC
theory.
Although there is research to support the view that
EWRDs play a role in the emergence of depression, few
studies have examined the relation between EWRDs and
depression among adolescents males (Nolen-Hoeksema
and Girgus 1994). The gender additive model proposed by
Stice and Bearman (2001) posits that male and female
adolescents possess certain shared risk factors for depres-
sion (e.g., low self-esteem, lack of perceived social sup-
port). Certain risk factors, however, are specific to
adolescent females (e.g., body mass, pressure to be thin,
thin-ideal internalization, body dissatisfaction, dieting, and

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bulimic symptoms), putting adolescent females at
increased risk for the development of depression. Overall,
the research findings seem to suggest that EWRDs may
constitute shared risk factors instead of being specific to
young women only. For example, in one study, bulimic
symptoms were found to predict depression in adolescent
males, although dietary restraint, body dissatisfaction, and
ideal body image were not predictive of depression among
adolescent males (Bearman and Stice 2008). Further,
Santos et al. (2007) found that the gender additive model fit
for both male and female adolescents as opposed to only
for female adolescents. Paxton et al. (2006) examined the
prospective relation between body dissatisfaction, depres-
sion, and low self-esteem. The authors found that body
dissatisfaction was indeed a prospective risk factor for
depression and low self-esteem over a sustained period of
5 years among both male and female adolescents. How-
ever, there were developmental and gender differences.
Specifically, the findings demonstrated that body dissatis-
faction predicted depression and low self-esteem among
early but not mid-adolescent females, and mid- but not
early adolescent males.
There have also been studies exploring the relationship
between gender and ethnicity in the relation between
EWRDs and depression. Siegel (2002) conducted a longi-
tudinal study examining body image, depression, and self-
esteem, each assessed at two time points about 13 months
apart in a sample of adolescents. Consistent with previous
studies, adolescent females rated their bodies less posi-
tively than adolescent males. In addition to gender differ-
ences, ethnic differences were also found; African–
Americans had a more positive body image than the other
ethnic groups (i.e., White, Latino, Asian, and Other
Americans), who did not significantly differ from each
other. However, African–American women whose body
image became more negative experienced a significant
change in the level of depression, suggesting that changes in
body image and related changes in depression vary by
ethnicity. Siegel (2002) also found that a consistently neg-
ative body image and a body image that becomes more
negative over time were both associated with an increase in
depression. A change in body mass was a particularly strong
predictor of depressed mood among female adolescents.
Interestingly, a change in satisfaction with specific aspects
of the body predicted a change in depressed mood inde-
pendently of global assessments about the self (Siegel
2002). Thus, results from these studies provide evidence
that male and female adolescents may be more similar than
they are different with respect to EWRDs and depression. In
addition, with emerging evidence to support the premise
that adolescent males experience unique EWRDs that are
predictive of depression (e.g., Adams et al. 2005), a revision
of the gender additive model may need to be developed.
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The OBC theory states that individuals experience
negative cognitive processes related to the body and that
individuals who experience these negative thoughts tend to
engage in self-monitoring and experience body shame (see
Hyde et al. 2008). This theory has been applied to ado-
lescent females, who may be more likely to have negative
beliefs about their bodies as a result of the social and
biological aspects of puberty. Consistent with OBC theory,
Wichstrøm (1999) concluded that an extended gender-
intensification model can adequately explain almost all of
the gender differences in depressed mood. In Wichstrøm’s
study, body dissatisfaction emerged as a strong explanatory
variable in the final structural equation model predicting
depressed mood, which also included pubertal timing,
BMI, perceived obesity, feminine sex role orientation,
global physical appearance, and global self-worth. Wich-
strøm (1999) found that increased sex role orientation
during adolescence (triggered by age and pubertal devel-
opment) contributes to depressed mood among adolescent
females. Since global self-worth is constructed from dif-
ferent subdomains, most notably physical appearance
among adolescents, poor self-worth may result from body
dissatisfaction, which in turn leads to depression (Wich-
strøm 1999). OBC theory is useful in explaining a possible
mechanism by which cognitively based EWRDs may lead
to depression (i.e., experiencing body shame and body
surveillance could lead to depression). However, given that
OBC theory is a cognitively based theory, it does not
address the link between behavioral EWRDs and depres-
sion. Thus, a more comprehensive model of the relation
between EWRDs and depression is needed that encom-
passes the link between cognitive and behavioral EWRDs
and depression. Additionally, other psychological (e.g.,
suicidal thoughts and behaviors) and biological correlates
of EWRDs are important to consider.
Suicidal Thoughts and Behaviors
In addition to being predictive of depression, some studies
have shown that EWRDs are predictive of depression-
related adolescent mental health issues, including suicidal
thoughts and behaviors. A recent study examined the lon-
gitudinal relations of disordered eating, body dissatisfac-
tion, and obesity to suicidal behavior among male and
female adolescents (Crow et al. 2008). Results from this
study suggest that extreme (e.g., taking diet pills), but not
unhealthy (e.g., skipping some meals) weight control
behaviors are predictive of suicidal ideation and suicide
attempts in young women. A similar relationship was not
found for young men in this study. Interestingly, BMI,
body dissatisfaction, and unhealthy weight control behav-
iors (e.g., fasting, eating very little food, using a food
substitute, and smoking more cigarettes) did not predict
Clin Child Fam Psychol Rev (2010) 13:213–230
suicidal ideation or suicide attempts among young men or
young women at five-year follow-up. Considering a con-
tinuum of behaviors on which extreme weight control is
considered the most severe, it may be that the less severe
behaviors are predictive of depression, but are not predic-
tive of suicidal ideation or suicide attempts.
Biological Correlates of Weight Changes and Appetite
Disturbances
In collectively considering the findings from the studies
reviewed, it is important to emphasize the biological cor-
relates of some EWRDs, such as changes in weight status
and appetite disturbances. In a recent review, Maxwell and
Cole (2009) identified body dissatisfaction, dieting, and
stress as psychological variables that affect the relation
between depression and weight and appetite changes dur-
ing adolescence. According to the Diagnostic and Statis-
tical Manual of Mental Disorders-IV, Text Revision
(DSM-IV-TR; American Psychiatric Association 2000),
appetite disturbances are a key symptom of depression.
There are several biological correlates of weight and
appetite disturbances that may moderate the relationship
between weight and appetite change and depression during
adolescence (e.g., hormonal changes, regulation of the
reward system, hypothalamic activation; see Maxwell and
Cole 2009 for a comprehensive review). In addition to
identifying important psychological and biological corre-
lates of weight and appetite changes related to depression
in adolescence, Maxwell and Cole (2009) reviewed studies
that had examined weight change and appetite disturbances
as a symptom of depression during adolescence. It was
noted that depressed adolescents were more likely to report
both increases and decreases in weight change and appetite
disturbances than non-depressed adolescents, but that
weight loss and decreased appetite were more prevalent
than weight gain and increased appetite (Maxwell and Cole
2009). In general, the review by Maxwell and Cole (2009)
provides support for the premise that appetite disturbances
and subsequent weight changes in adolescence may
increase the risk for the development of depression (also
see Georgiades et al. 2006).
Summary of Review
Upon an in-depth evaluation of the research studies
included in this review, it is suggested that EWRDs often
precede the development of depression, particularly in
early adolescent females (Rierdan et al. 1989; Santos et al.
2007; Stice and Bearman 2001; Stice et al. 2000). Although
EWRDs are not typically thought of as risk factors for
221
depression, the majority of the findings reviewed suggest
that a prospective association between EWRDs and
depression exists (Rierdan et al. 1989; Santos et al. 2007;
Stice and Bearman 2001; Stice et al. 2000).
In synthesizing the findings reviewed, a key implication
seems to be that EWRDs and depression both have an
underlying cognitive component (in addition to a biological
component proposed by Maxwell and Cole 2009). The
underlying cognitive component is also seen across the
theories that explain the relationship between EWRDs and
depression. The cognitive component may include faulty
body perceptions (e.g., body dissatisfaction), self-surveil-
lance, and appearance comparisons. One mechanism to
explain how EWRDs may lead to the development of
depression is that once negative cognitions are internalized,
this affects self-esteem, which then leads to depressed
mood or more generalized unhappiness. A study by Pesa
et al. (2000) found that body image was an important factor
in overweight female adolescents’ psychological adjust-
ment, as measured by self-esteem. According to Pesa et al.
(2000), body image is thought to be comprised of two
dimensions: the perceptual (evaluation of the size of one’s
body) and the cognitive (attitude toward one’s body). It is
not clear whether body image represents a unique construct
or whether it is merely a component of self-esteem.
However, according to the literature on body image, the
self-esteem of adolescent females is heavily dependent
upon how she feels about her body (Pesa et al. 2000).
During adolescence especially, body image becomes a
highly salient component of one’s identity. Furthermore,
EWRDs such as changes in body satisfaction have been
found to predict depression independently of one’s global
assessment of the self (Siegel 2002), suggesting that EW-
RDs, though related to self-esteem, may also be considered
a distinct construct. Regardless of whether body image is a
component of self-esteem or a unique construct, the pro-
posed pathway between EWRDs, low self-esteem (i.e.,
feelings of worthlessness in DSM-IV-TR terms), and
depression seems plausible.
In sum, each of the theories used to explain the evidence
on the relation between EWRDs and depression (i.e., the
dual pathway model of bulimic pathology, the gender
additive model, and the OBC theory) has strengths and
limitations. To advance the study of adolescent depression,
a conceptual model of adolescent depression has been
developed that highlights the factors relevant to under-
standing the role of EWRDs in the emergence of depres-
sion in adolescence. Additionally, explanatory mechanisms
of the dual pathway model of bulimic pathology and the
OBC theory have been incorporated into the conceptual
model of adolescent depression to augment understanding
the relation between EWRDs and depression in
adolescence.
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222 Clin Child Fam Psychol Rev (2010) 13:213–230

An Integrated Theoretical Model of Adolescent
Depression
In addition to the common risk factors for depression
identified in the literature (e.g., genetics, peer relationships,
poor emotion regulation), the findings reviewed suggest
that EWRDs are a key set of risk factors for depression.
Given that EWRDs often emerge during pre- or early
adolescence (McVey et al. 2004), developmentally appro-
priate models of adolescent depression could highlight the
connection between the underlying cognitive component
and the role that EWRDs play in one’s self-esteem. Fur-
thermore, such models should include fundamental risk and
protective factors associated with depression (e.g., school-
connectedness, families, peers, the media, and stressful life
events) and emphasize the role of EWRDs.
Figure 1 presents a novel integrated theoretical model
proposed to explain the development of depression in
adolescence that includes the role of EWRDs. This model
addresses some of the limitations in the current develop-
mental psychopathology literature and addresses the issues
previously discussed (i.e., including empirically supported
risk factors and contextual and psychological process
variables in the model). The model is based on previous
models of adolescent development and depression descri-
bed in the literature (e.g., Hammen and Rudolph 2003;
Maxwell and Cole 2009). Factors associated with depres-
sion across the life span can be divided into three empiri-
cally supported domains: (1) Genetic, Biological, and
Gender Influences, (2) Sociocultural Influences including
families and other interpersonal relationships (e.g., peer
and romantic partners), and (3) Thoughts, Feelings,
Behaviors, and Life Stress. Within the Genetic, Biological,
and Gender Influences domain, life span models of
depression describe common factors that contribute to
depression including genetic influences such as a family

DEPRESSION

1. Genetic,
Biological, and 2. Sociocultural
Gender Influences 3. Thoughts, Feelings, Behaviors, & Life Stress
Influences

Genetic Influences Family Emotional Functioning / Impulse Control

(e.g., family Experiences
history of
psychopathology) Individual Characteristics
Interpersonal
(e.g., self-esteem, resilience, psychological strengths)
Experiences (e.g.,
Biological weight-based
Influences (e.g., teasing; dating and
temperament, Cognitive Processes / Vulnerabilities
hormones, peer relationships)
(e.g., dysfunctional eating cognitions such as
serotonin)
internalization of thin ideal, body dissatisfaction, and
Media discrepancy between ideal and perceived body type)
Weight Status

Culture / Ethnic Maladaptive Behaviors (e.g., changes in appetite and

Age and Pubertal identity weight status, dieting, purging)
Status
Socioeconomic
Gender status (SES) Negative Event / Life or Interpersonal Stress

Fig. 1 Developmental influences on the emergence of depression
across childhood and adolescence. Theoretical developmental model
of depression in childhood and adolescence that describes the
fundamental risk and protective factors associated with depression
and emphasizes the role of eating- and weight-related disturbances
(EWRDs). Factors associated with depression across the life span can
be divided into three key empirically supported domains: (1) Genetic,
Biological, and Gender Influences, (2) Sociocultural Influences
including families and other interpersonal relationships (e.g., peer
and romantic partners), and (3) Thoughts, Feelings, Behaviors, and
Life Stress. It is proposed that these Genetic, Biological, and Gender
Influences help shape the foundational relationship that a child has
with his or her family and other Sociocultural Influences. These
sociocultural experiences influence a child and adolescent’s develop-
ing Thoughts, Feelings, Behaviors, and Life Stress related to
depression, including cognitive processes and vulnerabilities. Model
adapted from Hammen and Rudolph (2003) and Maxwell and Cole
(2009) and incorporates a cognitive vulnerability framework

123
Clin Child Fam Psychol Rev (2010) 13:213–230
history of depression and individual biological influences
including temperament and hormones. For example, fam-
ily, twin, and adoption studies have provided strong evi-
dence for genetic predisposition to depression (Sullivan
et al. 2000; Wallace et al. 2002). Findings from twin
studies have reported heritability rates between 40 and 70%
(Kendler et al. 1993; McGuffin et al. 1996). Specific to
adolescence, pubertal and weight status are associated with
depression onset in adolescence (Nolen-Hoeksema and
Girgus 1994), as well as the emergence of gender differ-
ences in depression, and underscore the importance of
assessing BMI and weight status (Maxwell and Cole 2009).
It is proposed that these Genetic, Biological, and Gender
Influences help shape the foundational relationship that a
child has with his or her family (Paikoff and Brooks-Gunn
1991) and other Sociocultural Influences. Various aspects
of family experiences, such as parental discipline style,
cohesiveness, family conflict, parental rejection, and
parental monitoring are frequently studied and are often
found to predict higher levels of depression (Angold 1988;
Field et al. 2001; Meyerson et al. 2002; Muris et al. 2001;
Van Voorhees et al. 2008). These family experiences also
influence how a teen interacts with peers in a bidirectional
relationship (Cooper and Cooper Jr 1992). Of particular
importance to adolescents is the role that media, culture,
and ethnic identity development play in their psychological
functioning including depression (Dillman Carpentier et al.
2008). The media is particularly relevant to understanding
the development of negative weight-related cognitions that
may contribute to young people being vulnerable to
depression given the media’s portrayal of young women.
Also, socioeconomic status has been shown to affect ado-
lescent depression (Angold 1988; Van Voorhees et al.
2008).
Next, these sociocultural experiences influence a child
and adolescent’s developing Thoughts, Feelings, and
Behaviors related to depression including cognitive pro-
cesses and vulnerabilities. For example, adolescents may
develop negative views of themselves based on experi-
encing weight-teasing by families and peers (Crow et al.
2008; Eisenberg et al. 2003) and an internalized thin-ideal
for their body type based on the media (Keery et al. 2004).
These dysfunctional cognitive styles along with poor
emotion regulation skills may contribute to the develop-
ment of maladaptive eating behaviors (e.g., dieting). These
issues may then contribute to the emergence of depression
(Rierdan et al. 1989; Santos et al. 2007; Stice and Bearman
2001; Stice et al. 2000). Alternatively, the relationship
between cognitive style and depression may be affected by
a negative life event, salient individual moderators relevant
to adolescence (e.g., self-esteem), or psychological
strengths (Eberhart and Hammen 2006; Muris et al. 2001;
Paunesku et al. 2008).
223
In sum, there are few published comprehensive devel-
opmental models of depression that describe established
risk and protective factors unique to adolescence. The
proposed model integrates salient factors related to the
development of adolescent depression and is based on
contemporary research findings. In contrast to previous
models, it incorporates both cognitive and behavioral
EWRDs. This model is dynamic and predicts bidirectional
influences within and across the levels of adolescent
functioning (e.g., Genetic, Biological, and Gender Influ-
ences, Sociocultural Influences, and Thoughts, Feelings,
Behaviors, and Life Stress). Overall, this model presents a
theoretical framework useful for conceptualizing adoles-
cent depression. On a conceptual level, the model can be
used to integrate the broad theoretical underpinnings of
adolescent depression, and on a practical level, the model
can be used in research to test specific relationships pro-
posed in the model (e.g., the effect of media on body
dissatisfaction). For example, in terms of testing specific
sociocultural, individual, and cognitive relationships
among depressed adolescents, it could be useful to examine
the role of weight-based teasing and media influence
on self-esteem, that in turn affect the development of
dysfunctional eating cognitions that are intensified in
response to an adolescent negative event, such as a
romantic break-up.
Research Limitations and Future Research
Based on this review, the following limitations are identi-
fied in the research literature on EWRDs and depression in
adolescence. These include methodological issues, lack of
diverse samples, and excluding additional risk and pro-
tective factors that are relevant to understanding depression
in adolescence.
Methodological Issues
There are several prominent methodological issues in the
extant literature that, if addressed, could move forward the
research agenda in this area. These issues include, among
others, the selection of research measures, design of the
research studies, and statistical analysis of the data. With
respect to research measures, a major limitation of the
current literature is that different measures have been used
across studies to tap into constructs, such as body image,
body dissatisfaction, negative eating cognitions, and eating
behavior disturbances. The use of different measures con-
tributes to issues in the generalizability of the research
findings, as well as the comparison of research findings
across studies. On a positive note, some of the most
common measures in this area of research have established
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224
psychometric properties including the Dutch Eating
Behaviors Questionnaire (van Strien et al. 1986; measure
of eating behavior), the Eating Disorder Inventory (Garner
et al. 1983; measure of dysfunctional eating cognitions and
behaviors), the Perception of Teasing Scale (Thompson
et al. 1995; measure of weight-teasing by others), and the
Body Image States Scale (BISS; Cash et al. 2002; measure
of body image).
Regarding measures of self-esteem and depression, the
Rosenberg Self-Esteem Scale (Rosenberg 1965) has been
employed relatively consistently across studies that have
included self-esteem as a predictor. However, this scale
does not contain an item that specifically addresses self-
esteem related to physical appearance, which is an
important aspect of adolescent self-worth. The measure of
depression most commonly used in the studies reviewed is
the Center for Epidemiologic Studies—Depression Scale
(CES-D; Radloff 1977), yet its use has been inconsistent as
well. Lastly, some studies employed outdated measures
that do not have established psychometric properties (e.g.,
Body Parts Satisfaction Scale; Berscheid et al. 1973).
To address the diversity of EWRDs used across studies,
it would be beneficial to develop a research battery that can
be used by researchers who are interested in exploring this
area further. This battery could be multidisciplinary in
nature and include standardized and widely used measures
of EWRDs, including body dissatisfaction, body image,
negative eating cognitions, depression, body weight and
height, perceptions of weight-teasing, disordered eating,
and nutritional intake. Maxwell and Cole (2009) suggest
the importance of including distinct measures of weight
gain, weight loss, appetite increase, and appetite decrease.
This would permit examination of the predictive nature of
these behaviors on the emergence of depression.
Researchers should also incorporate physical measures of
weight status as opposed to self-report. When departing
from more standardized or widely used measures,
researchers should clearly explain the construct they are
investigating and provide a rationale for the measure being
used.
Second, with respect to research designs, several studies
reviewed herein employed cross-sectional designs (e.g.,
Keery et al. 2004; Thompson et al. 1999; Wichstrøm 1999).
Longitudinal designs with greater than two time points or
waves are ideal to examine developmental trajectories of
depression and could allow for more sophisticated statistics
such as multilevel modeling (MLM) to be employed. MLM
facilitates the examination of risk and protective factors
that affect developmental trajectories (e.g., depression
across adolescence). Researchers can also use MLM to
explore time-varying (e.g., self-esteem) and time-invarying
(e.g., gender, ethnicity) factors that affect developmental
trajectories. One can also determine the effect of predictors
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Clin Child Fam Psychol Rev (2010) 13:213–230
on the initial onset and rate of change of growth trajectories
(Singer and Willett 2003). Thus, the use of prospective
designs allows for more complex analyses of the factors
that affect the developmental trajectories of depression in
adolescence.
Other inconsistencies across the research studies include
the age range of participants (adolescents ranged in age
from 12 to 17 years in the studies reviewed) and the dif-
ferent follow-up times across longitudinal studies. These
limitations make it difficult to draw general conclusions
about exactly when the relationship between EWRDs and
depression is most salient among adolescents, although
preliminary evidence suggests that this may be in early
adolescence. Future research should use age-matched
controls to compare prevalence rates of weight and appetite
disturbances in depressed and non-depressed samples
(Maxwell and Cole 2009).
Future research could also make use of secondary data
analysis involving large population-based surveys to
investigate the relationship between EWRDs and depres-
sion. These surveys provide opportunities to include
diverse measures that investigate multiple domains related
to the developmental process, cross-informant information,
and longitudinal data. Population-based surveys address
the logistic challenges of longitudinal community-based
surveys, including economical cost, attrition of sample
over time, and, consequently, retaining a sample repre-
sentative of the population (Bullock 2007; Cummings et al.
2000). Population-based surveys such as the National
Longitudinal Study of Adolescent Health (Carolina Popu-
lation Center 2009) and the National Longitudinal Survey
of Children and Youth (Statistics Canada 2008) are ideal to
address limitations in the research literature to date
including the previous use of small sample sizes, lack of
findings relating to adolescent males, and the absence of
exploring EWRDs in relation to other risk and protective
factors associated with depression among adolescents.
Research Samples
Another limitation in the research literature is the general
exclusion of adolescent males, individuals who are over-
weight and obese, as well as culturally diverse groups.
First, although there are few research studies on EWRDs
and depression, preliminary research provides some inter-
esting findings using male samples (see Paxton et al. 2006).
For example, the prevalence of body dissatisfaction among
young men is increasing, and male body dissatisfaction
differs qualitatively from female body dissatisfaction
(Adams et al. 2005; Jones et al. 2008). Adolescent females
commonly want to lose weight, whereas adolescent males
are more typically divided into those wishing to gain
weight and those wishing to lose weight. Furthermore,
Clin Child Fam Psychol Rev (2010) 13:213–230
findings from a recent longitudinal study examining the
role of weight loss and muscularity concerns in predicting
body dissatisfaction among early adolescent males suggest
that there may be developmental variations in the relative
predictive ability of these variables (Jones et al. 2008).
Also, there are clinically significant correlates of body
image disturbance in young men, including eating disor-
ders, muscle dysmorphia, and steroid and other substance
abuse (e.g., Adams et al. 2005; Cafri et al. 2006). More-
over, one recent study found that BMI predicted body
dissatisfaction and was also found to be predictive of body
change strategies in preadolescent boys (Ricciardelli et al.
2006). In other research involving depression as the out-
come variable, BMI has typically not been found to be a
significant predictor of depression when body dissatisfac-
tion or an indicator of weight perception is included in the
analyses. These findings underscore the importance of
tapping into an adolescent’s body perceptions as opposed
to only measuring physical characteristics.
Based on these research findings, there are many ave-
nues to explore in future research regarding EWRDs and
depression using both male samples and exploring gender
differences. For instance, future research could study males
across childhood, adolescence, and emerging adulthood in
order to identify the developmental trajectories of EWRDs
and depression, as well as the longitudinal relation between
these constructs. Additionally, future research involving
male samples should strive to include relevant predictor
variables (e.g., body dissatisfaction, importance placed on
weight and muscles) including sociocultural influences
such as perceived pressure to look a certain way from
parents, peers, and media.
Second, in addition to males, individuals who are
overweight and obese should be included in future research
on the relation between EWRDs and depression. Given that
obesity is a significant international public health issue,
depression researchers could consider obesity and its
associated EWRDs in terms of its prospective relation to
depression. Individuals who experience both obesity and
depression may face particular risks to physical and mental
health and well-being (Markowitz et al. 2008). Obesity
may increase one’s risk for depression and depression may
promote obesity. A theoretical model including behavioral,
cognitive, biological, and social mechanisms has been
proposed by Markowitz et al. (2008) to explain the bidi-
rectional pathway between obesity and depression. One
mechanism by which obesity may be a risk factor for
depression is through body dissatisfaction (Markowitz
et al. 2008).
Related to expanding the literature in this area by
including research on obesity, it would also be useful to
further understand the relationship between EWRDs and
eating disorders, and the potential similarities and
225
differences in the temporal trajectories of youth who
present with only EWRDs, EWRDs and depression, eating
disorders, and eating disorders and comorbid depression
(Santos et al. 2007). Although eating disorders and
depression share several common risk factors, for example,
poor family relations, poor body image, and psychopa-
thology (Graber et al. 1994), it is unclear whether these are
fundamentally different groups or if they vary along a
continuum of severity. The existing literature does not
address this issue, and future research should aim to
identify factors that differentiate these groups.
Third, cultural differences in eating attitudes, behaviors,
and body image have been investigated in studies com-
paring Black, White, Asian, and Latino adolescents (e.g.,
Barry and Grilo 2002; Bisaga et al. 2005). However, dif-
ferences across other ethnic groups and cultures (e.g.,
Aboriginal) have yet to be examined. Culture plays an
important role in the development of dietary customs, and
as such, likely plays a role when eating attitudes and
behaviors become unhealthy or dysfunctional. In a study
that examined gender and ethnicity patterns in eating and
body image disturbances in a clinical sample of adoles-
cents, a significantly higher proportion of the White
American group reported body image concerns than did
African American and Latino American groups, who did
not differ significantly from one another (Barry and Grilo
2002). A gender by ethnicity interaction was observed,
such that eating-related and body image concerns did not
differ significantly across ethnic groups for adolescent
males. However, White American adolescent females had
significantly more eating related and body image concerns
than both African American and Latino American ado-
lescent females. Thus, since many of the studies reviewed
sampled primarily White, middle and upper class ado-
lescent females, future research should aim to employ
heterogeneous samples, especially with respect to eth-
nicity, socioeconomic status, and gender. The use of
population-based national surveys may also address these
issues.
Risk and Protective Factors
So far, the majority of research in this area has broadly
examined factors such as self-esteem in relation to EWRDs
and depression. Future research should attempt to examine
the role of self-esteem as a potential mediator in the rela-
tion between EWRDs and depression by parsing out vari-
ous types of self-esteem to determine their relation to
depression. However, within the broader depression liter-
ature, there are other variables that would be useful to
incorporate. Using a developmental psychopathology
framework, future research should continue to examine
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226
protective factors related to depression. In keeping with the
idea that EWRDs have been shown to predict depression,
perhaps the inverse relationship also holds true. That is,
healthy eating habits and a positive attitude toward ones
physical appearance may act as protective factors against
the development of depression and other psychopathology.
Another area that may be worthwhile to investigate
further is the relationship between adolescent risk behav-
iors (e.g., substance use and peer violence), EWRDs, and
depression. For example, many empirical studies have
suggested a strong relationship between adolescent sub-
stance use and depression (Hallfors et al. 2005; Roberts
et al. 2007). Given the developmental context of adoles-
cence, it is important to examine the critical role that
parents, peers, negative cognitions, and behaviors play in
the lives of adolescents who engage in substance use and
experience depression (Margolese et al. 2005; Nash et al.
2005; Suldo et al. 2008). Understanding EWRDs may shed
light on the relation between such risk behaviors and
depression. For example, poor body image and low self-
esteem are associated with depression, which in turn may
contribute to a youth engaging in inappropriate substance
use or other risk behaviors. To date, this has not been
studied in the research literature. Thus, there are many
avenues to explore in future research on EWRDs and
depression that could strengthen the implications of this
research on the assessment, intervention, and prevention of
depression particularly in adolescence.
Implications
Assessment
Within clinical practice, many children and adolescents
present with depression and comorbid disorders (e.g.,
anxiety, substance use, and trauma). In addition to stan-
dard assessment of broad internalizing and externalizing
symptoms, it would be useful to assess EWRDs given
their reported link to mental health outcomes. This may
include a brief screener measure that assesses some of the
key EWRDs identified in this review and based on exist-
ing literature. For example, a useful construct to measure
is body image due to its significant role in the established
link between EWRDs and depression. Additional clinical
research is needed to determine the predictive utility
(validity and reliability) of such measures in assessing
depressive disorders, but findings from the current review
imply that further investigation is certainly warranted.
Siegel (2002) found that a change in satisfaction with a
specific body part predicted changes in depression, inde-
pendently of global assessments of the self, providing
further support for the assessment of body image. Pettit
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Clin Child Fam Psychol Rev (2010) 13:213–230
et al. (2006) found that increases in appetite in depressed
adolescents were predictive of recurrent episodes, whereas
decreased appetite, weight gain, and weight loss were not,
suggesting that specific EWRDs may be able to distin-
guish between those that remit and those that do not.
Similarly, Rierdan et al. (1989) found that body image
represented a distinguishing feature in chronic and tran-
sient profiles of depression. These findings highlight the
potential role of measuring EWRDs not only to predict
future depression, but also to differentiate between various
clinical profiles.
Moreover, evidence supports the importance of assess-
ing EWRDs in both depressed and non-depressed adoles-
cents. Maxwell and Cole (2009) summarize interesting and
preliminary research highlighting gender differences in
weight and appetite symptoms in non-depressed and
depressed adolescents. In non-depressed samples, adoles-
cent females exhibit more dysfunctional weight and appe-
tite behaviors than adolescent males; however, although
these behaviors remain elevated, differences disappear in
adolescent depressed samples. In other words, as adoles-
cent males become depressed, they experience the greatest
relative change in weight and appetite changes compared to
their female counterparts. In terms of assessment implica-
tions, this research provides the rationale for assessing
EWRDs in non-depressed adolescents, and the importance
of assessing these behaviors particularly in young depres-
sed men. Additional support for the importance of assess-
ing for EWRDs within a clinical context includes research
suggesting that specific problems with eating or weight
during adolescence were associated with an increased risk
for physical and mental disorders beyond depression during
early adulthood (Johnson et al. 2002a).
Intervention
Within the adolescent depression literature, cognitive-
behavioral interventions have been shown to be efficacious
with depressed adolescents (see David-Ferdon and Kaslow
2008 for a recent review). Interventions for EWRDs and
depression have been mainly brief (i.e., four sessions) and
focus on improving body dissatisfaction within manualized
cognitive-behavioral therapy (CBT) programs (e.g., Bear-
man et al. 2003). It could be beneficial to address a variety
of presenting EWRDs throughout cognitive-behavioral
interventions consistent with models of treatment for dis-
ordered eating. An informative treatment model for these
purposes is Fairburn et al. (2003) transdiagnostic model of
CBT for disordered eating. Within this model, the authors
describe four fundamental vulnerabilities that contribute to
the maintenance of disordered eating that are addressed
throughout sessions: (1) clinical perfectionism, (2) core
low self-esteem, (3) intense mood states, and (4)
Clin Child Fam Psychol Rev (2010) 13:213–230
interpersonal difficulties. While Fairburn et al. (2003)
conceptualized this treatment for disordered eating, several
of the mechanisms within the transdiagnostic model may
be particularly relevant to the treatment of individuals
presenting with symptoms of depression and EWRDs, such
as low self-esteem, intense mood states, and interpersonal
difficulties. Future research is needed to examine the rel-
evance of these CBT models to improving EWRDs and
depression symptoms.
It is noteworthy that patients presenting with several
previous episodes of depression may benefit from inter-
ventions focused on improving body image and adjust-
ments to appetite, given that negative body image and
increases in appetite have been found to be associated with
recurrent depression (Pettit et al. 2006; Rierdan et al.
1989). Recent research suggests that body dissatisfaction
may also be a risk factor in the bidirectional pathway
between obesity and depression (Markowitz et al. 2008).
For such individuals, the benefits of addressing EWRDs in
intervention could be amplified by intercepting a possible
feedback loop. Findings related to gender differences imply
that treatment with depressed adolescent males could focus
on coping with appetite and weight changes, but that
addressing EWRDs in intervention is important for both
male and female adolescents.
Prevention
Mental health prevention in childhood and adolescence
provides a cost-effective opportunity to decrease the
prevalence and reduce the impact of mental illness in
adults since the majority of mental disorders, the most
common of which is depression, often first emerge in
adolescence. By contextualizing EWRDs as a significant
risk factor for depression, findings from the current review
emphasize the role of EWRDs in preventive efforts
extending beyond preventing eating disorders. In this vein,
it is important to address EWRDs for at least two reasons.
First, previous studies have illustrated that EWRDs and
weight-based teasing may lead to depression and in severe
cases, suicide (Brausch and Gutierrez 2009; Crow et al.
2008; Eisenberg et al. 2003). Second, this review has
shown the prospective relationship between EWRDs and
depression. Thus, prevention efforts targeting EWRDs
have the potential to affect a subset of adolescents from
developing depression or suicidal tendencies through
encouraging healthy eating attitudes and behaviors and
healthy body image (Pesa et al. 2000).
With respect to prevention with children and adoles-
cents specifically, universal strategies, or those targeting
all children regardless of individual risk level, are often
preferred in the school setting because of their ability to
reach a large number of students (Shochet et al. 2001).
227
Studying EWRDs within this context is congruent with
these universal approaches since eating is a core human
behavior. While universal programs tend to be widely-
used in school-based prevention (Shochet et al. 2001),
universally applied depression and eating disorder
prevention programs have yielded inconsistent results
(Littleton and Ollendick 2003; Merry et al. 2004). Merry
et al. (2004) found that while targeted programs led to
short-term reduction in depressive symptoms, universal
programs were not effective. Similarly, in a critical review
of psychoeducational programs that have been developed
to prevent the onset of disordered eating, Littleton and
Ollendick (2003) found that such programs were incon-
sistent in preventing future eating disorders, disordered
eating, and negative body image. While many of the
programs were effective at increasing knowledge about
nutrition, healthy eating, exercise, healthy weight man-
agement, self-esteem, and the signs and symptoms of
eating disorders, the majority of universal programs did
not lead to significant changes in body image or disor-
dered eating behaviors. Based on their findings, the
authors suggested implementing stronger, more compre-
hensive programs that extend over a long period of time
and focus on individuals with different levels of symptoms
(Littleton and Ollendick 2003).
In integrating the findings from both depression and
disordered eating prevention research, programs seeking to
prevent future onset of depressive symptoms by targeting
EWRDs should be selective for both depressive symptoms
and disordered eating behaviors. School-based programs
could be universally applied to all students within a class or
school, but clinically meaningful groups could be com-
prised based on pre-screening assessments of depressive
symptoms, body dissatisfaction, disordered eating behav-
iors, and desire to change those behaviors. Furthermore, to
effectively target self-esteem and body image, clinicians
could modify program components and curriculum
according to screening results, clinical characteristics, and
risk status of these groups.
Programs can also be tailored to the developmental
level and gender of participants. The eating disorders
prevention literature has noted the increased efficacy of
addressing EWRDs in pre- and early adolescence, a time
when these types of behaviors and cognitions begin to
emerge (McVey et al. 2004). Similarly, prevention of
depression via EWRDs should also target this age group.
In addition to internalizing symptoms, research has also
identified a link between EWRDs and externalizing
behaviors (e.g., aggression, substance use) in adolescent
women (Crow et al. 2006; Marmorstein et al. 2007;
Thompson et al. 1999), further emphasizing the applica-
bility of EWRDs in prevention among children and
adolescents.
123
228
Conclusion
This paper reviewed the current literature on the relation
between EWRDs and depression in adolescence. In syn-
thesizing the findings, there is support for the inclusion of
EWRDs in contemporary models of adolescent depression.
Looking ahead, gaps in the current literature represent
many possibilities for future research that have the poten-
tial to answer complex questions including establishing
clinically relevant relations between EWRDs, depression,
and other salient psychological variables. The use of
diverse samples with both male and female participants and
the use of a developmental perspective will contribute to
our understanding of EWRDs as a vulnerability factor for
depression for a subset of adolescents. The findings also
have broader implications for depression research in gen-
eral, where although it is common to measure appetite and
weight changes in depression scales (typically using a
single item), it would be useful to examine this more
comprehensively and consider the constructs of body
image and other EWRDs. In conclusion, further research is
needed to clarify and expand the role of EWRDs in
developmental frameworks of depression in adolescence.
Acknowledgments Funding for this project was provided in part by
the LaMarsh Centre for Research on Violence and Conflict Resolu-
tion, York University, Toronto, Canada. The authors would like to
thank the reviewers for comments on earlier versions of this
manuscript.
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