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Perfectionism and Eating-Related Symptoms
in Young Children: A Systematic Review
Mariacarolina Vacca and Caterina Lombardo
Abstract
Perfectionism is a multidimensional personality trait that encom-
passes two higher-order dimensions: Perfectionistic Strivings (i.e.,
the strive to achieve exceedingly high standards) and Perfectionistic
Concerns (i.e., negative self-evaluation and fear of failure). Both
dimensions are related to eating disorders (EDs) in clinical and
community adults. The association between perfectionism and
EDs has also been observed in children but, to date, no review
has summarized the relevant empirical findings with children
under the age of 14. English-language studies published up to
2019 were searched in online databases (PsycINFO, Medline,
PsycArticle) by using the pertinent keywords. Eligible publica-
tions reported at least one relationship between perfectionism
and eating-related symptoms in children. Data were examined
using the Quality Assessment Tool for Observational Cohort and
Cross-Sectional Studies. For the 14 studies that were included, 11
studies provided evidence supporting the relationship between
perfectionism and ED outcomes, with the majority adopting a
unidimensional approach for perfectionism assessment. Among
the studies that used multidimensional assessment of perfection-
ism, the majority supported the involvement of perfectionistic
strivings. Implications of results for children are discussed.
Keywords: perfectionism, eating symptoms, disordered eating, children,
childhood onset
238 Perspectives Volume 4, Issue 2 • Fa ll 2 019 Perfectionism and Eating Symptoms in Children 239
Perfectionism is a personality trait that has been defined as
the tendency to set high standards, be excessively susceptible to
critical evaluation, and strive for flawlessness (Frost, Marten, Lahart,
& Rosenblate, 1990; Smith, Saklofske, Yan, & Sherry, 2015; Stoeber &
Otto, 2006). Empirical evidence supports a multidimensional nature
of perfectionism, leading to the distinction between two major
dimensions: the engaging in negative self-evaluation and the striv-
ing to achieve high standards of performance (Dunkley, Blankstein,
Halsall, Williams, & Winkworth, 2000; Stoeber & Gaudreau, 2017).
The first dimension, called Perfectionistic Concerns (PC) is related to
perceived stress, neuroticism, avoidant coping (Stoeber & Childs,
2010), and high levels of psychopathology symptoms (Limburg,
Watson, Hagger, & Egan, 2017). On the other hand, Perfectionistic
Striving (PS) has been generally associated with adaptive outcomes,
such as positive affect, intrinsic motivation to succeed (Eum & Rice,
2011; Taylor, Papay, Webb, & Reeve, 2016), and trait emotional intel-
ligence (Smith, Saklofske, & Yan, 2015). However, evidence also has
shown that PS might act as a risk factor for depressive symptoms
after controlling for PC (Smith et al., 2016), for suicide (Flett, Hewitt,
& Heisel, 2014), and obsessive-compulsive disorder (Soreni et al.,
2014), providing support for the notion that PS may not always be
beneficial (Limburg et al., 2017). Thus, the effects of PS appear to
be mixed since there are findings indicating that it may be both
a risk factor (Smith et al., 2016) and a protective factor (Hill, 2014)
after controlling for PC. Moreover, PS in adults consistently predicted
negative outcomes related to eating disorders (EDs; Bardone-Cone,
et al., 2007; Esposito, Stoeber, Damian, Alessandri, & Lombardo, 2017;
Stoeber, Madigan, Damian, Esposito, & Lombardo, 2017). A relatively
recent meta-analysis on the relationship between psychopathology
outcomes and perfectionism dimensions highlighted the role of PC
for most outcomes, with the exception of eating disorders symptoms
where PS and PC explained the same variance (Limburg et al., 2017).
In samples of children and adolescents, the PS dimension has been
found to encompass not only the beneficial attitude to set high
standards, but also the negative outcomes usually attributed to
the self-criticism over imperfections (McCreary, Joiner, Schmidt, &
Ialongo, 2004; O’Connor, Dixon, & Rasmussen, 2009; Sironic & Reeve,
2015). It is possible that for children and adolescents the perceived
pressures to be perfect from significant others are more relevant
than self-expectations (Muuss, 2006).
Despite the prevalent empirical support towards PS as positive
for personal growth and psychological adjustment (Stoeber, 2018),
this adaptive role needs to be reconsidered and clarified in the
specific case of Feeding and Eating Disorders (EDs). EDs are clinical
conditions characterized by persistent disturbances of eating behav-
ior that result in the altered consumption or absorption of food and
significantly impairs physical health or psychosocial functioning
(American Psychiatric Association, 2013). Present diagnostic systems
identify six main mutually exclusive syndromes: Pica, rumination
disorder, and avoidant/restrictive food intake disorder that occurs for
the first time in early childhood; Anorexia Nervosa (AN) and Bulimia
Nervosa (BN) whose peak age of onset is estimated around middle
and late adolescence (15–19 years of age); and Binge Eating Disorder
(BED) that was found to occur at age 16 (Stice, Killen, Hayward, &
Taylor, 1998). The first three syndromes may be indicated as feed-
ing disorders given their main characteristic is the disturbed eating
behavior and there are no weight and body shape concerns, while
Anorexia Nervosa, Bulimia Nervosa, and Binge Eating Disorder also
show a common psychopathology dealing with body image and
body dissatisfaction (Fairburn, 2008).
Epidemiological studies have suggested that the prevalence
of EDs among children and adolescents has increased significantly
in the last decades (Madden, Morris, Zurynski, Kohn, & Elliot, 2009;
Rosen, 2010) and several studies have focused on EDs with childhood
onset from 7–14 years of age (Fairburn & Brownell, 2005). EDs at
this age are more difficult to diagnose, because they often present
atypically. A case-register study found that the incidence of diagnosis
of Anorexia Nervosa was between ages 10–14 years (Micali et al.,
240 Perspectives Volume 4, Issue 2 • Fa ll 2 019 Perfectionism and Eating Symptoms in Children 241
2013; as cited in Nicholls & Bryant-Waugh, 2009). Epidemiological
evidence reported the presence of binge eating and overeating was
among 6- to 13-year-old normal and overweight children (Nicholls
& Bryant-Waugh, 2009). Although epidemiological data concerning
the incidence of Bulimia Nervosa in children are not available, many
clinical referrals reported evidence in individuals between ages 7–13
years (Fairburn & Brownell, 2005).
Moreover, the adoption of dysfunctional eating behavior (i.e.,
restrictive eating, limiting food intake for controlling weight, etc.)
and body weight and shape dissatisfaction, which are widespread
in adolescent girls and adult women of western societies, develops
early in life, namely by age 6 (Harriger, & Thompson, 2012; Smolak,
2012) or earlier (Tremblay & Limbos, 2009). Longitudinal data showed
that subclinical eating disorder pathology in children predicted the
subsequent development of full syndrome EDs (Calam & Waller, 1998).
Therefore, an early detection of the risk factors for developing EDs
may improve prognosis and treatment outcomes in younger age
groups (D’Souza, Forman, & Austin, 2005; Nicholls, Lynn, & Viner, 2011).
Perfectionism is among the most relevant candidate risk factor
for these eating disorders. Individuals with ED symptoms attempt
to apply their perfectionistic standards in order to control eating,
shape, and weight (Fairburn, Cooper, & Shafran, 2003). High lev-
els of perfectionism predicted lower likelihood of remission at 12
months follow-up in a sample of ED sufferers (Johnston et al., 2018).
When researchers compared adult patients with Anorexia Nervosa
and Bulimia Nervosa to non-clinical groups and patients with other
psychiatric diagnoses, perfectionism was higher in patients with ED
(Dahlenburg, Gleaves, & Hutchinson, 2019; Kehayes, Smith, Sherry,
Vidovic, & Saklofske, 2019), thus suggesting the role of perfectionism
is also a maintaining factor for these disorders in adults (Egan, Wade,
& Shafran, 2011).
The patterns of association between perfectionism and ED
symptoms in adolescents are similar to those observed in older
age groups. Many studies have found significant cross- sectional and
prospective associations between perfectionism and ED symptoms in
non-clinical samples of children and adolescents (Campbell, Boone,
Vansteenkiste, & Soenens, 2018; Ferreiro, Seoane, & Senra, 2012). In
non-clinical, early adolescents, perfectionism increased the risk for
EDs one year later (Boone, Soenens, & Luyten, 2014). Perfectionistic
traits were associated with bulimic symptoms in a sample of adoles-
cents (with a mean age of 13.9 years) after two years (Boone, Soenens,
& Braet, 2011). Moreover, perfectionism in girls of ages 12–16 years
assessed at either Time 1 or Time 2 (two years later) predicted the
young adult onset of Anorexia Nervosa eight years after the first
assessment period (Tyrka, Waldron, Graber, & Brooks Gunn, 2002).
These finding suggest that perfectionism may be implicated in the
pathogenesis of ED symptoms. Although results are consistent for
adolescents and adults, the role of perfectionism in children’s ED
symptoms has not been widely studied. To date, no systematic review
has explicitly examined the association between perfectionism and
ED symptoms in studies focused on children. Therefore, the aim
of this research was to summarize studies that have assessed the
relationship between perfectionism and ED symptoms in children
under the age of 14 years.
Method
Search Procedure
According to Preferred Reporting Items for Systematic Reviews
and Meta-Analyses (PRISMA; Moher, Liberati, Tetzlaff, & Altman, 2009)
recommendations, peer-reviewed articles up to 2019 on the relationship
between perfectionism and dysfunctional eating habits in childhood
were identified. Articles were searched in online databases (PsycINFO,
Medline, PsycArticle), by using the following keywords: “(perfectionism
OR perfection OR perfectionistic OR perfectionist) AND (eating disorders
OR anorexia OR bulimia OR disordered eating) AND (child OR children
OR childhood OR kid OR kids).” We read the titles of all papers gener-
ated by our search results. If the title of the paper contained words
or phrases related to perfectionism (e.g., perfectionistic tendencies/
242 Perspectives Volume 4, Issue 2 • Fa ll 2 019 Perfectionism and Eating Symptoms in Children 243
dimension), eating pathology and symptoms (e.g., eating restriction, food
consumption), and childhood (e.g., youth, young, infants, pediatric), the
paper was retrieved. To be include in the review the following criteria
were satisfied: (a) Participants under 14 years of age (or studies with
sub analyses on this age group), (b) Examining either perfectionism and
eating symptoms (using validated instruments with child self-report
data and/or using a structured psychiatric interview), and (c) Reporting
of at least one indicator of the relationship between perfectionism and
eating symptoms, habits, or attitudes.
Studies published in non-English language journals and non-peer
reviewed journals were excluded. Articles that reported case reports, case
series, qualitative studies, dissertations, review papers, and conference
abstracts without published full articles were excluded. Clinical trials
were not included in this review given that we were not interested
in specific intervention effects. Because the objective of this review
was to explore if perfectionism was associated to ED symptoms in
children, we did not exclude studies merely focused on a non-dimen-
sional measurement of this relationship (e.g., canonical correlation). For
this reason, many studies showed different results depending of the
specific association considered. Given the variety of study designs, a
meta-analysis was not feasible.
Data Extraction and Risk of Bias
Data extraction was performed by the first author of this paper.
The information extracted from each study included: the references,
the study design, the sample characteristics (mean age, age range, sex,
presence of illness/psychopathology, etc.), the perfectionism measure
used, and the eating-related symptoms assessed. Data were examined
using the National Institutes of Health (NIH) Quality Assessment Tool for
Observational Cohort and Cross-Sectional Studies (Sanderson, Tatt, &
Higgins, 2007). The tools included 14 items for evaluating potential flaws
in study methods or implementation (e.g., “good,” “fair,” or “poor” quality).
Items reviewed included representativeness of sampling procedure,
blinding of outcome assessors, response rate, validity of measurement
methods, the provision of specific statistical parameters, and control of
potential confounding variables. The criteria were rated as either yes,
no, or “other” (i.e., cannot determine, not reported, or not applicable). A
score equal to or less than 6 indicated a poor methodological quality, a
score of 7 reflected a medium-risk quality, and a score of greater than
7 suggested a good methodological quality of studies. The maximum
score that can obtain using this tool is 14.
Study selection. A total of 399 records were identified through
electronic databases. After duplicates were removed, 288 studies were
examined. Two-hundred and ten articles were globally screened on the
inclusion and exclusion criteria, of which 196 were excluded. The main
reasons for exclusion were an incongruent age range of participants and
the lack of an indicator of the relationship between perfectionism
and ED symptoms. The remaining 14 papers were included in the
review. A summary of study selection process is outlined in Figure 1.
Records indentified through
database searching (n = 399)
Records after duplicates
removed (n=288)
Records excluded (n=78)
Full-text articles assessed for
eligibility (n = 210)
Studies included (n=14)
Dissertation (n = 21)
Book (n = 18)
Review (n = 21)
Case report (n = 9)
No English Language (n= 9)
Articles excluded, with reason
No English Language ( n=1)
Qualitative study (n = 12)
No child self-report data (n=5)
Clinical trial (n = 15)
Inclusion of adults (n = 81)
Inclusion of middle and
late adolescents (n = 74)
Lack of variables indicator (n = 8)
Identification InclusionElegibility Screening
Figure 1. Student selection flow diagram
244 Perspectives Volume 4, Issue 2 • Fa ll 2 019 Perfectionism and Eating Symptoms in Children 245
Study
Cross-Sectional Design
Years of Age Population Perfectionism Eatings Findings Quality
rating
Faust, 1984 11–14
Mage= 13.2
N = 65
no clinical females EDI-P EDI Perfectionism was not
related to Drive for Thinness 5
Simmons et al., 2001 Mage= 12.8
(7th grade)
N = 392
no clinical females EDI-P TREI,
EDI
Perfectionism accounted for
variance in BUILT-R 6
McVey et al., 2002
Mage= 12.9
(7th and 8th
grade)
N = 363
no clinical females CAPS ChEAT
Self-Oriented Perfectionism
significantly associated with
ChEAT total score
9
Kirsh et al., 2007 12–14
Mage= 13.36
N = 25 females in
treatment for an ED,
25 age-matched
controls
CAPS ChEAT
Self-oriented perfectionism was
found to distinguish the ED group
from their controls
6
Goodwin et al., 2011 Mage= 12.8
(7th grade)
N = 1,488
no clinical males
and females
CAPS CET, EDI
Self-perfectionism
cross-sectionally predicted
compulsive exercise in girls
6
Elizathe et al., 2016 9–13
Mage= 10.85
N = 37 females and
63 males (all over-
weight)
CPQ
(total score) ChEAT
Perfectionism cross-sectionally
predicted the presence of ED in
overweight children
7
van Noort et al., 2018 9.2 13.9
Mage= 12.2
N = 30 females with
early-onset AN, 30
healthy
FMPS
(total score) ChEDE
Patients with early-onset Anorexia
did not report higher FMPS than
healthy controls
5
Study
Longitudinal
Design
Years of Age Population Perfectionism Eatings Findings Quality
rating
Calam & Waller, 1998 11.9 – 13.9
Mage= 12.8
N = 92
no clinical females SCANS BITE,
EAT
Perfectionism was followed
by low levels of severity
of bulimic behaviors
10
Westerberg et al., 2008 11 –13 N = 567
no clinical females EDI-P ChEAT
Perfectionism year 1 was
associated with ChEAT year 3.
Perfectionism year 1 failed to
predict ChEAT year 3
7
Bachar et al., 2010 Mage= 12.8
(7th grade)
N = 243
no clinical females
HFMPS
(total score)
EAT,
EDFHI
Perfectionism failed to 13
distinguish ED sufferers from
non-ED sufferers
13
Westerberg et al., 2010 9 – 13 N= 516
no clinical females EDI-P ChEAT
The relation between EDI-P
year 1 and ChEAT year was
moderated by self-esteem
11
Ferreiro et al., 2012 9 – 12
Mage= 10.8
N = 465 no clinical
females and 477 no
clinical males
EDI-P ChEAT
EDI-P year 1 was associated
with ChEAT year 3. EDI-P year 1
predicted ChEAT year 3
11
Goodwin et al., 2014 12 – 14
Mage= 12.89
N = 148 males and
221 females CAPS CET,
EDI II
SOP 9-year 1 predicted
compulsive exercise
amoung males year 3
9
Wade et al., 2015
Mage= 13
(7th and 8th
grade)
N = 926
no clinical females FMPS EDE-Q
Perfectionistic Concerns were
correlated with all ED variables.
PC predicted the growth of ED
through Ineffectveness
10
Table 1
Overview of study characteristics
Note. Abbreviation: BITE, Bulimic Investigatory Test; CAPS, Child and Adolescent Perfectionism Scale; CED, Compulsive Exercise Test; ChEAT,
Eating Attitude Test for Children; CHEDE-Q, Children’s Eating Disorders ExaminationQuestionnaire; CPQ, Child Perfectionism Questionnaire;
EAT, Eating Attitude Test; EDE-Q, Eating Disorder Examination Questionnaire; EDFHI, Eating Disorder Family History Interview; EDI, Eating
Disorder Inventory; EDI-P, Eating Disorder Inventory-Perfectionism Scale; FMPS, Frost Multidimensional Perfectionism Scale ; HFMPS, Hewitt
& Flett Multidimensional Perfectionism Scale; SOP, Self-Oriented Perfectionism; TREI, Thinness and Restricting Expectancy Inventory. Overall
judgments regarded quality ratings of good (8-14), fair (7), or poor (1-6).
246 Perspectives Volume 4, Issue 2 • Fa ll 2 019 Perfectionism and Eating Symptoms in Children 247
Study characteristics. A cross-sectional design was employed
in seven articles, while the remaining were longitudinal studies (see
Table 1). Ten studies included only female participants. The number
of participants per study ranged from 25 to 1488, yet only one study
was relatively large with 1488 participants. The mean age across the
12 studies that reported mean age was 11.45 years. Most studies
were conducted on non-clinical samples, while only two studies
included patients with ED and age-matched healthy controls. The
scale most widely used for assessing disordered eating was the
Children version of Eating Attitudes Test (ChEAT; Maloney, McGuire,
& Daniels, 1988), followed by the Eating Disorder Inventory (EDI;
Garner, Olmsted, & Polivy, 1983) and the Children’s Eating Disorders
Examination-Questionnaire (ChEDE Q; Hilbert, Hartmann, & Czaja,
2008). Other assessment tools for ED symptoms were the Bulimic
Investigatory Test (BITE; Henderson & Freeman, 1987), the Thinness
and Restricting Expectancy Inventory (TREI; Atlas, Smith, & Hohlstein,
1988; Hohlstein et al., 1998; as cited in Simmons, Smith, & Hill, 2002)
and the Eating Disorder Family History Interview (EDFHI; Strober,
1987).
Perfectionism was measured through unidimensional or mul-
tidimensional instruments. Most of the studies (N = 5) that used a
unidimensional approach used the EDI-P, a subscale of the Eating
Disorder Inventory (EDI; Garner et al., 1983). The EDI-P consists of 6
items designed to evaluate the general tendency to set excessively
high standards and to be concerned about social expectations.
Another scale used to assess unidimensional perfectionism is the
Setting Conditions for Anorexia Nervosa Scale (SCANS; Slade &
Dewey, 1986). The scale includes 8 items that measure the desire
to complete tasks to the best of one’s ability. Higher scores reflect
greater levels of perfectionism. For multidimensional measures of
perfectionism, the Child and Adolescent Perfectionism Scale (CAPS;
Flett, Hewitt, Boucher, Davidson, & Munro, 2000) was used in four
studies. It includes two subscales: self-oriented perfectionism (SOP)
and socially prescribed perfectionism (SPP). The first scale reflects
the tendency to strive rigidly for perfection; on the other hand, SPP
addresses the need to meet perceived external expectations (Flett
et al., 2016). While SOP is identified as a marker of PS, SPP is an
indicator of PC (see Limburg et al., 2017). The Frost Multidimensional
Perfectionism Scale (FMPS; Frost et al., 1990) was used in two studies.
The scale included 35 items with a 5-point scale from 1 (strongly
disagree) to 5 (strongly agree). The items reflect six dimensions:
doubts about actions, concern over mistakes, personal standards,
parental expectations, parental criticism and organization. The Child
Perfectionism Questionnaire (CPQ) was used in one study. This scale
is comprised of 16 items reflecting two different dimensions of
perfectionism (Self-demands and Reactions to failure; Oros, 2003;
as cited in Elizathe, Arana, & Rutsztein, 2018). Although four studies
(Bachar, Gur, Canetti, Berry, & Stein, 2010; Elizathe et al., 2018; van
Noort et al., 2018) employed multidimensional measures to assess
perfectionism, researchers tended to use the total scores of these
scales. All studies that investigated the direction of the relationship
between perfectionism and eating disorders symptoms considered
perfectionism as a predictor and ED symptoms as the dependent
variable. Each study examined as outcomes one or more disturbed
eating attitude or behavior. Eleven out of the 14 studies included
reported at least one indicator of a significant relationship between
perfectionism and eating disorders symptoms.
Quality assessment. The quality of the papers, evaluated
through the NIH Quality Assessment Tool for Observational Cohort
and Cross-Sectional Studies (Sanderson et al., 2007), differed across
studies. Seven of them were scored as “good,” two studies reported
a medium risk of bias, and five studies showed a poor methodolog-
ical quality. The research question and the study population were
always clearly stated. Key confounding factors were assessed in eight
studies, and five studies discussed how the sample size needed to
detect a hypothesized difference in outcomes. The lowest score
estimated was 5 and the maximum was 13. The mean of the overall
quality score computed on the cross-sectional studies was 6.3 with
248 Perspectives Volume 4, Issue 2 • Fa ll 2 019 Perfectionism and Eating Symptoms in Children 249
a standard deviation (SD) of 1.27. On the other hand, longitudinal
studies showed higher quality scores that those with a cross-sectional
design, with a mean of 10.1 and a SD of 1.72.
Results
Studies adopting a cross sectional design
Half of the studies (n = 7) used cross-sectional designs to inves-
tigate associations between perfectionism and eating pathology in
children under the age of 14 years. In four studies (Elizathe et al.,
2018; Goodwin, Haycraft, Willis, & Meyer, 2011; Kirsh, McVey, Tweed, &
Katzman, 2007; McVey, Pepler, Davis, Flett, & Abdolell, 2002; Simmons
et al., 2002), a significant association between these two variables
was reported, while null association was reported in two studies
(Faust, 1984; van Noort et al., 2018). Among those studies that con-
firmed the association, three used a multidimensional approach to
evaluate perfectionistic tendencies (Goodwin et al., 2011; Kirsh et al.,
2007; McVey et al., 2002), and two studies used a one-dimensional
instrument (Elizathe et al., 2018; Simmons et al., 2002). The aspect
of perfectionism related to ED symptoms was the self-oriented per-
fectionism, one of the components of perfectionistic strivings in
non-clinical samples (McVey et al., 2002), in children with EDs (Kirsh
et al., 2007), and which predicted compulsive exercise symptoms
(Goodwin et al., 2011).
All of the studies that did not find a significant relationship
between perfectionism and ED outcomes employed the total score
of perfectionism measures (Faust, 1984; van Noort et al., 2018).
Inconsistent findings were reported for the association between
unidimensional perfectionism and drive for thinness (Faust, 1987).
Two studies were conducted on clinical samples using the EDI-P scale.
One study reported a significant relationship between perfectionism
and severity of ED symptoms (Elizathe et al., 2018), while the second
study did not report observed differences in perfectionistic traits
between ED patients and healthy controls (Van Noort et al., 2018).
A summary of the findings is provided in Table 2.
Studies adopting a longitudinal design
Seven studies used a prospective design. Five studies used the
total score to assess perfectionism, and two studies employed the
multidimensional approach. Six studies revealed that perfection-
ism significantly predicted severity of ED symptoms either when
multidimensional scales were used for measuring perfectionism
(Goodwin, Haycraft, & Meyer, 2014; Wade, Wilksch, Paxton, Byrne, &
Austin, 2015) or when a one-dimensional measure was used (Calam
& Waller, 1998; Ferreiro et al., 2012; Westerberg, Edlund, & Ghaderi,
Study PS PC Total score/
one dimension No relation
Cross-sectional
Faust, 1987 •
Simmons et al., 2001 •
McVey et al., 2002 •
Kirsh et al., 2007 •
Goodwin et al., 2011 •
Elizathe et al., 2016 •
van Noort et al., 2018 •
Longitudinal
Calam & Waller, 1998 •
Westerberg et al., 2008 •
Bachar et al., 2010 •
Westerberg et al., 2010 •
Ferreiro et al., 2012 •
Goodwin et al., 2014 •
Wade et al., 2015 •
Table 2
Overview of the Association Between Perfectionism and ED Outcomes
Note. Abbreviation: PS, Perfectionistic Strivings; PC, Perfectionistic Concerns
250 Perspectives Volume 4, Issue 2 • Fa ll 2 019 Perfectionism and Eating Symptoms in Children 251
2008; Westerberg-Jacobson, Edlund, & Ghaderi 2010). Several studies
found significant simple correlations both in the cross-sectional
and the follow-up phases, but a non-significant regression path
when assessing the predictive value of perfectionism. This pattern
suggests that the variance of ED outcomes may be explained by the
linear combination of other variables. For instance, one-dimensional
perfectionism (assessed with the EDI-P) of 13-year-old girls showed
significant and positive bivariate correlation with their ChEAT scores
three years later (Westerberg et al., 2008). However, when entered
in the regression analysis, baseline perfectionism was not a signif-
icant predictor of the girls’ eating disturbances at Year 3, because
their own Year 1 ChEAT and their fathers’ Year 1 EAT scores contrib-
uted most to the prediction of disturbed eating attitudes in Year
3. Westerberg et al. (2010) found that perfectionism of 13-year-old
girls was significantly correlated with their ChEAT scores eight years
later, though in the regression analysis, the “Wish to be thinner” at
Year 1 and the mothers’ rating on perfectionism at Year 1 became
the strongest predictors of Year 8 ChEAT. Westerberg et al. (2010)
reported a significant positive association between the baseline EDI-P
and the ChEAT scores at Year 8 only for the girls with low self-es-
teem, suggesting that high self-esteem could buffer the relation
between perfectionism and ED symptoms. Goodwin et al. (2014)
found that self-oriented perfectionism predicted compulsive exercise,
often associated with eating pathology, even after controlling for
the baseline level of eating disturbances. Significant prospective
association was found between perfectionism assessed at baseline
and disturbed eating attitude after three years (Ferreiro et al., 2012).
One study reported the unique role of perfectionistic concerns in
predicting ED symptoms (Wade et al., 2015). More specifically, it was
found that the direct relationship between perfectionistic concerns
and the ED risk at 4 weeks, 6 months, and 12 months from baseline
was significant, but small and negative. Although in all of the other
studies perfectionism had a positive relationship to ED symptoms,
one study found the opposite pattern: perfectionism was related to
less severe bulimic behaviors (Calam & Waller, 1998). Among those
studies that used the unidimensional assessment, one study did not
find that perfectionism at Time 0 was associated with ED symptoms
at Time 1 (Bachar et al., 2010). More specifically, the authors mea-
sured perfectionism at Time 0 in 243 seventh-grade students and
compared perfectionism total score in those who did and did not
suffer from eating disorders two years later (Time 1). The number
of students examined at Time 1, however, constituted only 11 cases
and 15 non-cases.
Discussion
The present systematic review investigated the relationship
between perfectionism and ED symptoms in children under 14 years
of age. Both cross-sectional and longitudinal studies were examined.
Although based on few and heterogeneous studies, results globally
suggest that, as in adulthood, the association between perfectionism
and ED symptoms is significant and positive. Most of the studies that
used a longitudinal design were rated as high-quality, while among
the cross-sectional studies, very few were rated as high-quality. Only
three studies out of 14 failed in reporting any association between
perfectionism and ED symptoms. Two of them were cross-sectional
(Faust, 1984; van Noort et al., 2018) and all had a small sample
size (see Table 1). It is possible that the lack of significant effects
is due to this small sample size. The associations found between
perfectionism and EDs may have been artificially increased due to
the use of the same questionnaire (namely the EDI; Garner et al.,
1983) for measuring both perfectionism and ED symptoms. However,
this is not likely the case, because the number of studies using this
instrument and reporting a significant association are only a small
percentage (36%) of our overall sample of studies.
The majority of the studies included in the present review used
a unidimensional approach either employing unidimensional mea-
sures (e.g., EDI-P by Garner et al., 1983; CPQ, Child Perfectionism
Questionnaire by Oros, 2003; SCANS by Slade & Dewey, 1986) or
252 Perspectives Volume 4, Issue 2 • Fa ll 2 019 Perfectionism and Eating Symptoms in Children 253
computing a total score from a multidimensional questionnaire
(MPS, Hewitt, Flett, Turnbull-Donovan, & Mikail, 1991; MPS, Frost et
al., 1990). Our findings support the involvement of PS as a poten-
tial risk factor for EDs, although most of these finding come from
cross-sectional designs. Only one longitudinal study reported that
PC increased the risk of EDs, thus confirming that for ED symptoms,
the involvement of PS and PC is mixed. Two longitudinal studies that
used multidimensional questionnaires (Frost et al., 1990; Hewitt et
al., 1991) found that in one study, there was a significant relationship
between EDs and PS (Goodwin et al., 2014), and in the other study,
the significant role of PC in predicting the growth of ED symptoms
was shown (Wade et al., 2015). Studies with a longitudinal design
are especially needed to examine PS and PC because those included
in the present review were of higher quality.
Cumulative evidence has supported that perfectionism may be
best explained by a multi-factor structure, and this is needed when
examining its relationship with eating disorder features (Pearson &
Gleaves, 2006). The increasing research on perfectionism in youth
has shown that different faces of perfectionism exist in children as
in adults (Leone & Wade, 2018). For instance, it has been estimated
that 25–30% of young people present maladaptive perfectionistic
traits (as cited in Flett et al., 2016). Further research should refer to
existing multifactorial models of childhood perfectionism to describe
the degree in which its different aspects are involved in ED symptoms.
Among studies that examined the multidimensional measures,
the majority showed a significant association between self-oriented
perfectionism, one component of perfectionistic strivings, and ED
symptoms. This finding is inconsistent with a growing body of
research that suggests a relatively equal contribution of PC and PS
perfectionism to explaining variance in ED outcomes (Limburg et
al., 2017). Although PS appears to be maladaptive in the context of
eating disorder (Bardone et al., 2007), the role of PC is also relevant
(Boone, Soenens, Braet, & Goossens, 2010). A possible explanation of
this finding may be the complex nature of childhood self-oriented
perfectionism, given that it may combine many elements, includ-
ing intrinsic motivation and introjected pressures to do the best in
achievement contexts (Flett et al., 2016). Thus, it may be possible that
for children and adolescents, the perceived pressures to be perfect
from significant others are more dysfunctional than the self-imposed
high standards (Muuss, 2006).
Following this line of reasoning, it may also be that only in
adults do social pressures and self-criticism (both encompassed by
the perfectionistic concerns dimensions) become more relevant than
in childhood. Further research is needed to examine more complex
relationships and the role of possible mediators and moderators.
Only one study showed that males who reported high levels of
perfectionism were also engaged in more problematic behavior
related to ED compared to females (Goodwin et al., 2014). However,
the researchers did not assess directly eating disorders symptoms but
measured compulsive exercise as a proxy, and this is consistent with
results in adulthood where compulsive exercise has been reported to
be more frequent among males (Guidi et al., 2009; Murray, Griffiths,
Rieger, & Touyz, 2014). Moreover, different mediators and modera-
tors such as self-esteem and parenting styles might show different
relationships among males and females (Boone et al., 2014; Vohs,
Bardone, Joiner, & Abramson, 1999). Much more research is needed
to understand the characteristics and associated factors of EDs in
young males. The findings of the present systematic review strongly
suggest that the interaction between moderators and mediators
in the longitudinal influences of fear of failure and achievement
strivings on children’s health, and especially in the field of eating
disorders, needs to be further investigated.
Implications and Conclusion
Although based on few studies, these findings have some impli-
cations for intervention research and clinical practice. First, more
investigation into the nature of childhood perfectionism and EDs
emerged. The complex nature of self-oriented perfectionism, one
254 Perspectives Volume 4, Issue 2 • Fa ll 2 019 Perfectionism and Eating Symptoms in Children 255
aspect of perfectionistic strivings, should be examined, especially
due to its association with ED symptoms. The way in which children
perceive their parents’ criticism and expectations has shown asso-
ciations with their own SOP (Harvey, Moore, & Koestner, 2017). An
evaluation of parent–child communication strategies could be useful
in order to examine mechanisms underlying children’s perception
of external family pressures. This issue makes relevant evaluating
children’s perception of sociocultural pressure regarding appearance.
Research showed that adolescence is a critical period in body image
development (Voelker, Reel, & Greenleaf, 2015) and that one of the
predictors of a negative body appearance is the perceived pressure
to be thin from family, friends, and the media (Rodgers, Paxton, &
McLean, 2014). Parental encouragement to control weight and shape
was found to be associated with body dissatisfaction in boys and girls
one year later (Helfert & Warschburger, 2011) and with perceived body
concerns among overweight adolescents (Helfert & Warschburger,
2013). Previous findings highlighted the role of media-internaliza-
tion in longitudinally predicting body dissatisfaction in schoolgirls
through its influence on social appearance comparison (Rodgers,
McLean, & Paxton, 2015). Moreover, the influence of friends and
peers on adolescents’ body dissatisfaction has been well supported
in literature (for a review, see Webb & Zimmer-Gembeck, 2014). We
suggest that the influence of external and sociocultural pressures on
body concerns and eating behavior may reflect the same mechanism
in children as well as in adolescents. Further research is requested
to investigate the specific role of perceived external expectation
in explaining body-related concerns and eating disturbances in
childhood. The current findings also suggest that focusing on per-
fectionism may improve treatment protocols designed for children.
Consistent with this conclusion are previous experiences indicating
that group cognitive behavioral therapy for perfectionism helped to
reduce adolescents’ criticisms about body weight and shape (Hurst
& Zimmer-Gembeck, 2015; Wilksch, Durbridge & Wade, 2008). A
program for children with perfectionism could also involve the
examination of children’s susceptibility to the cultural expectations
of thinness and perfection. A primary educational institution may
provide the promotion of students’ awareness of the influence of
sociocultural agents on the development of body image disturbance
and subsequent ED pathology.
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