Eating Behaviors 14 (2013) 497–499
Contents lists available at ScienceDirect
Eating Behaviors
Family functioning and risk factors for disordered eating Jennifer Lyke ⁎, Julie Matsen Richard Stockton College of New Jersey, NJ, USA
a r t i c l e
i n f o
Article history: Received 29 January 2013 Accepted 14 August 2013 Available online 31 August 2013 Keywords: Family functioning Eating disorder risk Young women
a b s t r a c t This study investigated whether any of seven factors of family dysfunction predicted five risk factors for developing eating disorders in young adult women. Participants completed demographic questions, the McMaster Family Assessment Device (Epstein, Baldwin, & Bishop, 1983) and the Setting Conditions for Anorexia Nervosa Scale (Slade & Dewey, 1986) online. Five stepwise multiple regressions evaluated whether FAD scores predicted any of the eating disorder risk factors. Unhealthy affective responsiveness predicted general dissatisfaction and social and personal anxiety, and unhealthy general functioning predicted adolescent problems. No FAD factors predicted perfectionism or weight control. These results confirm the importance of families' affective responsiveness and general functioning to the risk of developing eating disorders. However, the lack of relationship among problem-solving, communication, roles, affective involvement, or behavior control with any of the risk factors for eating disorders warrants further investigation. © 2013 Elsevier Ltd. All rights reserved.
1. Family functioning and risk factors for disordered eating Family dysfunction has long been suspected as a contributing factor in the development of disordered eating. Indeed, clinicians have postulated the existence of a particular family structure that encourages and maintains patterns of disordered eating (Minuchin, Rosman, & Baker, 1978). While research does not indicate a particular model of family functioning that necessarily leads to disordered eating, there is evidence to suggest that family dysfunction is indeed related to disordered eating. Family functioning can be broken down into a number of factors that influence the overall health of the family unit. McMaster's Family Assessment Device (FAD; Epstein, Baldwin, & Bishop, 1983) identifies seven factors that may indicate dysfunction. The general functioning of a family refers to the overall health of the family system. Disordered eating families generally tend to be more dysfunctional than normal controls (McGrane & Carr, 2002) and the quality of family functioning influences the development and maintenance of eating disorders. (North, Gowers, & Byram, 1997; Strober, Freeman, & Morrell, 1997; Wewetzer, Deimel, Herpertz-Dahlmann, Mattejat, & Remschmidt, 1996). Problem solving refers to the family's ability to resolve problems at a level that maintains effective family functioning. Impaired problem solving has been linked to disordered eating, with women with disordered eating reporting their families as having more difficulty with problem solving than normal controls (Baylan, Erol, & Kilicoglu, 2009; McGrane & Carr, 2002; Waller, Calam, & Slade, 1989) and being less
⁎ Corresponding author at: School of Social and Behavioral Sciences, 101 Vera King Farris Drive, Galloway, NJ 08205, USA. Tel.: +1 609 626 6839. E-mail address: [email protected] (J. Lyke). 1471-0153/$ – see front matter © 2013 Elsevier Ltd. All rights reserved. http://dx.doi.org/10.1016/j.eatbeh.2013.08.009
capable of redefining stressful events to make them more manageable (Cunha, Relvas, & Soares, 2009). Communication, or the exchange of information among family members, has also been linked to disordered eating, with eating disordered families reporting poorer functioning in this area (Lattimore, Wagner, & Gowers, 2000; Steiger, Liquornik, Chapman, & Hussein, 1991). Family roles, or established patterns of behavior for handling basic family functions, are also related to eating behavior, with women displaying disordered eating patterns reporting greater family difficulty in this area (Baylan et al., 2009; McGrane & Carr, 2002). Affective responsiveness, the extent to which family members are able to experience appropriate affect, has also been associated with disordered eating. Compared to normal controls, eating disordered families report greater difficulty with appropriate affective response (Kugu, Akyuz, Dogan, Ersan, & Izgic, 2006; McGrane & Carr, 2002; Steiger et al., 1991). Affective involvement, or the extent to which family members are interested in and place value on each other's activities and concerns, is also related to disordered eating. Women exhibiting disordered eating reported their families as having more problems with affective involvement (Baylan et al., 2009; Waller et al., 1989). Families with disordered eating have been characterized as over involved, which does not necessarily connote a positive form of closeness. Indeed, women with anorexia perceived family members as responsible and guilty for all other family members' problems while reporting less emotional involvement among family members (Cunha et al., 2009). Finally, the way a family expresses and maintains standards for behavior, or behavioral control, is also related to disordered eating, with eating disordered families reporting problems in this area (Waller et al., 1989). This evidence strongly suggests multiple relationships between family dysfunction and disordered eating. However, factors that contribute
498
J. Lyke, J. Matsen / Eating Behaviors 14 (2013) 497–499
to actually developing an eating disorder may or may not differ from factors that contribute to the risk of developing the disorder. In fact, using Slade and Dewey's (1986) five risk factors for developing disordered eating (general life dissatisfaction, social and personal anxiety, perfectionism, adolescent problems, and weight control), Felker and Stivers (1994) found that only family expressiveness related to risk of developing an eating disorder in adolescents. In the present study, we extended these results by investigating whether any of the factors of family dysfunction predicted any of five risk factors for developing eating disorders in young adult women.
3. Results 3.1. Descriptive statistics Participants (N = 91) were females between 18 and 25 years old (M = 21.15, SD = 1.62). The racial/ethnic background of participants was 90.1% Caucasian, 1.1% African–American, 4.4% Hispanic, 3.3% Asian, and 1.1% identified as Other. Ninety-six percent of the sample were single and 4% were married. In terms of educational status, 1.1% never graduated from high school, 53.8% had a high school diploma or G.E.D., 22% had an Associates degree, 22% had a Bachelors degree, and one participant was missing data for educational status.
2. Method 3.2. Regressions
2.1. Participants Participants were 91 undergraduate women between the ages of eighteen and 25 who completed questionnaires in partial fulfillment of psychology course requirements.
2.2. Instruments 2.2.1. Demographics Participants reported their age, race/ethnicity, marital status, and highest level of education.
2.2.2. McMaster Family Assessment Device (FAD; Epstein et al., 1983). The FAD is one of the most thoroughly studied tools for assessing family functioning (Ridenour, Daley, & Reich, 1999) It is a sixty-item self-report questionnaire for assessing participants' views of their family functioning. Scoring produces ratings on seven aspects of family functioning: problem-solving, communication, roles, affective responsiveness, affective involvement, behavior control, and general functioning. Low scores indicate healthier functioning than higher scores. The FAD has been shown to have test–retest reliability, internal scale reliabilities, factorial validity, and discriminant validity (Kabacoff, Miller, Bishop, Epstein, & Keitner, 1990; Miller, Epstein, Bishop, & Keitner, 1985.
2.2.3. Setting Conditions for Anorexia Nervosa Scale (SCANS; Slade & Dewey, 1986). The SCANS is a self-report screening device for identifying individuals at risk of Anorexia or Bulimia Nervosa. The instrument yields five scale scores for general dissatisfaction, social and personal anxiety, perfectionism, adolescent problems, and weight control. Butler, Newton, and Slade (1988) have demonstrated validity and reliability of this scale.
2.3. Procedure Participants completed informed consent, the demographic questions, the FAD and the SCANS online. Five stepwise multiple regressions were used to evaluate whether demographic variables and/or FAD scores predicted each of the eating disorder risk factors.
Results of the first regression indicated only affective responsiveness predicted general dissatisfaction, R2 = .313, R2adj = .304, F(1, 78) = 35.52, p b .001, with unhealthy affective responsiveness associated with higher levels of general dissatisfaction. Results from the second regression indicated only affective responsiveness predicted social and personal anxiety, R2 = .230, R2adj = .220, F(1, 78) = 23.28, p b .001, with unhealthy affective responsiveness associated with higher levels of social and personal anxiety. Results from the third regression indicated that none of the family functioning variables significantly predicted perfectionism. Results from the fourth regression indicated only general functioning predicted adolescent problems, R2 = .064, R2adj = .052, F(1, 77) = 35.38, p b .05, with unhealthy general functioning associated with higher levels of adolescent problems. Results from the fifth regression indicated that none of the family functioning variables significantly predicted weight control (Table 1). 4. Discussion Results indicated that only affective responsiveness and general family functioning were predictive of any of the risk factors for developing eating disorders. Unhealthy levels of affective responsiveness were related to both general dissatisfaction and social and personal anxiety. In addition, unhealthy general family functioning was predictive of adolescent problems, but none of the predictors related significantly to perfectionism or weight control. These results appear to correspond to those of Felker and Stivers (1994) who found that family expressiveness was the only factor of family environment that correlated with risk of eating disorders in adolescents. However, given the extensive literature indicating relationships among multiple dimensions of family functioning and eating disordered behavior, the lack of relationship among problem-solving, communication, roles, affective involvement, or behavior control with any of the risk factors for eating disorders was unexpected. The main limitation of this study is that it relied on participants' selfreport. In addition, since the sample used in this study was primarily Caucasian and exclusively young women, it is possible these results do not generalize to other groups. Future research should aim to establish the generalizability of these results with other populations, investigate the mechanisms of these associations, and ultimately identify treatment interventions based on those findings. Role of Funding Sources There was no funding provided for this study.
Table 1 Coefficients for model variables predicting Eating Disorder Risk Factors. Risk factor
Predictor variable
B
B
t
p
General dissatisfaction Social/Personal anxiety Perfectionism Adolescent problems Weight control
Affective responsiveness Affective responsiveness N/A General functioning N/A
6.261 4.344 – .995 –
.559 .479 – .253 –
5.960 4.825 – 2.290 –
.000 .000 – .025 –
Contributors Lyke designed the study and conducted the statistical analysis. Matsen conducted literature review and wrote the introduction. Both authors contributed to and approved the final manuscript.
Conflict of Interest Both authors declare that they have no conflicts of interest.
J. Lyke, J. Matsen / Eating Behaviors 14 (2013) 497–499
References Baylan, G., Erol, A., & Kilicoglu, A. (2009). Predictors of anorectic and bulimic symptoms in adolescent girls. Bulletin of Clinical Psychopharmacology, 19(4), 407–413. Butler, N., Newton, T., & Slade, P. (1988). Validation of a computerized version of the SCANS questionnaire. The International Journal of Eating Disorders, 8(2), 239–241. Cunha, A., Relvas, A., & Soares, I. (2009). Anorexia nervosa and family relationships: Perceived family functioning, coping strategies, beliefs, and attachment to parents and peers. International Journal of Clinical and Health Psychology, 9(2), 229–240. Epstein, N.B., Baldwin, L. M., & Bishop, D. S. (1983). The McMaster Family Assessment Device. Journal of Marital and Family Therapy, 9, 171–180. Felker, K. R., & Stivers, C. (1994). The relationship of gender and family environment to eating disorder risk in adolescents. Adolescence, 29(16), 821–834. Kabacoff, R. I., Miller, I. W., Bishop, D. S., Epstein, N.B., & Keitner, G. I. (1990). A psychometric study of the McMaster Family Assessment Device in psychiatric, medical, and nonclinical samples. Journal of Family Psychology, 3(4), 431–439. Kugu, N., Akyuz, G., Dogan, O., Ersan, E., & Izgic, F. (2006). The prevalence of eating disorders among university students and the relationship with some individual characteristics. The Australian and New Zealand journal of psychiatry, 40(2), 129–135. Lattimore, P. J., Wagner, H. L., & Gowers, S. (2000). Conflict avoidance in anorexia nervosa: An observational study of mothers and daughters. European Eating Disorders Review, 8, 355–368. McGrane, D., & Carr, A. (2002). Young women at risk for eating disorders: Perceived family dysfunction and parental psychological problems. Contemporary Family Therapy, 24(2), 385–395.
499
Miller, I. W., Epstein, N.B., Bishop, D. S., & Keitner, G. I. (1985). The McMaster Family assessment Device: Reliability and validity. Journal of Marital and Family Therapy, 11(4), 345–356. Minuchin, S., Rosman, B.L., & Baker, L. (1978). Psychosomatic families. Cambridge: Harvard University Press. North, C., Gowers, S., & Byram, V. (1997). Family functioning and life events in the outcome of adolescent anorexia nervosa. The British Journal of Psychiatry, 171, 545–549. Ridenour, T. A., Daley, J. G., & Reich, W. (1999). Factor analyses of the Family Assessment Device. Family Process, 38, 497–510. Slade, P. D., & Dewey, M. E. (1986). Development and preliminary validation of SCANS: A screening instrument for identifying individuals at risk of developing anorexia and bulimia nervosa. The International Journal of Eating Disorders, 5(3), 517–538. Steiger, H., Liquornik, K., Chapman, J., & Hussein, N. (1991). Personality and family disturbances in eating disorder patients; Comparison of “restricters” and “purgers” to normal controls. The International Journal of Eating Disorders, 10, 501–512. Strober, M., Freeman, R., & Morrell, W. (1997). The long-term course of severe anorexia nervosa in adolescents: Survival analysis of recovery, relapse, and outcome predictors over 10–15 years in a prospective study. The International Journal of Eating Disorders, 22, 339–360. Waller, G., Calam, R., & Slade, P. (1989). Eating disorders and family interaction. The British Journal of Clinical Psychology, 28, 285–286. Wewetzer, C., Deimel, W., Herpertz-Dahlmann, B., Mattejat, F., & Remschmidt, H. (1996). Follow-up investigation of family relations in patients with anorexia nervosa. European Child & Adolescent Psychiatry, 5, 18–24.
Contents lists available at ScienceDirect
Eating Behaviors
Family functioning and risk factors for disordered eating Jennifer Lyke ⁎, Julie Matsen Richard Stockton College of New Jersey, NJ, USA
a r t i c l e
i n f o
Article history: Received 29 January 2013 Accepted 14 August 2013 Available online 31 August 2013 Keywords: Family functioning Eating disorder risk Young women
a b s t r a c t This study investigated whether any of seven factors of family dysfunction predicted five risk factors for developing eating disorders in young adult women. Participants completed demographic questions, the McMaster Family Assessment Device (Epstein, Baldwin, & Bishop, 1983) and the Setting Conditions for Anorexia Nervosa Scale (Slade & Dewey, 1986) online. Five stepwise multiple regressions evaluated whether FAD scores predicted any of the eating disorder risk factors. Unhealthy affective responsiveness predicted general dissatisfaction and social and personal anxiety, and unhealthy general functioning predicted adolescent problems. No FAD factors predicted perfectionism or weight control. These results confirm the importance of families' affective responsiveness and general functioning to the risk of developing eating disorders. However, the lack of relationship among problem-solving, communication, roles, affective involvement, or behavior control with any of the risk factors for eating disorders warrants further investigation. © 2013 Elsevier Ltd. All rights reserved.
1. Family functioning and risk factors for disordered eating Family dysfunction has long been suspected as a contributing factor in the development of disordered eating. Indeed, clinicians have postulated the existence of a particular family structure that encourages and maintains patterns of disordered eating (Minuchin, Rosman, & Baker, 1978). While research does not indicate a particular model of family functioning that necessarily leads to disordered eating, there is evidence to suggest that family dysfunction is indeed related to disordered eating. Family functioning can be broken down into a number of factors that influence the overall health of the family unit. McMaster's Family Assessment Device (FAD; Epstein, Baldwin, & Bishop, 1983) identifies seven factors that may indicate dysfunction. The general functioning of a family refers to the overall health of the family system. Disordered eating families generally tend to be more dysfunctional than normal controls (McGrane & Carr, 2002) and the quality of family functioning influences the development and maintenance of eating disorders. (North, Gowers, & Byram, 1997; Strober, Freeman, & Morrell, 1997; Wewetzer, Deimel, Herpertz-Dahlmann, Mattejat, & Remschmidt, 1996). Problem solving refers to the family's ability to resolve problems at a level that maintains effective family functioning. Impaired problem solving has been linked to disordered eating, with women with disordered eating reporting their families as having more difficulty with problem solving than normal controls (Baylan, Erol, & Kilicoglu, 2009; McGrane & Carr, 2002; Waller, Calam, & Slade, 1989) and being less
⁎ Corresponding author at: School of Social and Behavioral Sciences, 101 Vera King Farris Drive, Galloway, NJ 08205, USA. Tel.: +1 609 626 6839. E-mail address: [email protected] (J. Lyke). 1471-0153/$ – see front matter © 2013 Elsevier Ltd. All rights reserved. http://dx.doi.org/10.1016/j.eatbeh.2013.08.009
capable of redefining stressful events to make them more manageable (Cunha, Relvas, & Soares, 2009). Communication, or the exchange of information among family members, has also been linked to disordered eating, with eating disordered families reporting poorer functioning in this area (Lattimore, Wagner, & Gowers, 2000; Steiger, Liquornik, Chapman, & Hussein, 1991). Family roles, or established patterns of behavior for handling basic family functions, are also related to eating behavior, with women displaying disordered eating patterns reporting greater family difficulty in this area (Baylan et al., 2009; McGrane & Carr, 2002). Affective responsiveness, the extent to which family members are able to experience appropriate affect, has also been associated with disordered eating. Compared to normal controls, eating disordered families report greater difficulty with appropriate affective response (Kugu, Akyuz, Dogan, Ersan, & Izgic, 2006; McGrane & Carr, 2002; Steiger et al., 1991). Affective involvement, or the extent to which family members are interested in and place value on each other's activities and concerns, is also related to disordered eating. Women exhibiting disordered eating reported their families as having more problems with affective involvement (Baylan et al., 2009; Waller et al., 1989). Families with disordered eating have been characterized as over involved, which does not necessarily connote a positive form of closeness. Indeed, women with anorexia perceived family members as responsible and guilty for all other family members' problems while reporting less emotional involvement among family members (Cunha et al., 2009). Finally, the way a family expresses and maintains standards for behavior, or behavioral control, is also related to disordered eating, with eating disordered families reporting problems in this area (Waller et al., 1989). This evidence strongly suggests multiple relationships between family dysfunction and disordered eating. However, factors that contribute
498
J. Lyke, J. Matsen / Eating Behaviors 14 (2013) 497–499
to actually developing an eating disorder may or may not differ from factors that contribute to the risk of developing the disorder. In fact, using Slade and Dewey's (1986) five risk factors for developing disordered eating (general life dissatisfaction, social and personal anxiety, perfectionism, adolescent problems, and weight control), Felker and Stivers (1994) found that only family expressiveness related to risk of developing an eating disorder in adolescents. In the present study, we extended these results by investigating whether any of the factors of family dysfunction predicted any of five risk factors for developing eating disorders in young adult women.
3. Results 3.1. Descriptive statistics Participants (N = 91) were females between 18 and 25 years old (M = 21.15, SD = 1.62). The racial/ethnic background of participants was 90.1% Caucasian, 1.1% African–American, 4.4% Hispanic, 3.3% Asian, and 1.1% identified as Other. Ninety-six percent of the sample were single and 4% were married. In terms of educational status, 1.1% never graduated from high school, 53.8% had a high school diploma or G.E.D., 22% had an Associates degree, 22% had a Bachelors degree, and one participant was missing data for educational status.
2. Method 3.2. Regressions
2.1. Participants Participants were 91 undergraduate women between the ages of eighteen and 25 who completed questionnaires in partial fulfillment of psychology course requirements.
2.2. Instruments 2.2.1. Demographics Participants reported their age, race/ethnicity, marital status, and highest level of education.
2.2.2. McMaster Family Assessment Device (FAD; Epstein et al., 1983). The FAD is one of the most thoroughly studied tools for assessing family functioning (Ridenour, Daley, & Reich, 1999) It is a sixty-item self-report questionnaire for assessing participants' views of their family functioning. Scoring produces ratings on seven aspects of family functioning: problem-solving, communication, roles, affective responsiveness, affective involvement, behavior control, and general functioning. Low scores indicate healthier functioning than higher scores. The FAD has been shown to have test–retest reliability, internal scale reliabilities, factorial validity, and discriminant validity (Kabacoff, Miller, Bishop, Epstein, & Keitner, 1990; Miller, Epstein, Bishop, & Keitner, 1985.
2.2.3. Setting Conditions for Anorexia Nervosa Scale (SCANS; Slade & Dewey, 1986). The SCANS is a self-report screening device for identifying individuals at risk of Anorexia or Bulimia Nervosa. The instrument yields five scale scores for general dissatisfaction, social and personal anxiety, perfectionism, adolescent problems, and weight control. Butler, Newton, and Slade (1988) have demonstrated validity and reliability of this scale.
2.3. Procedure Participants completed informed consent, the demographic questions, the FAD and the SCANS online. Five stepwise multiple regressions were used to evaluate whether demographic variables and/or FAD scores predicted each of the eating disorder risk factors.
Results of the first regression indicated only affective responsiveness predicted general dissatisfaction, R2 = .313, R2adj = .304, F(1, 78) = 35.52, p b .001, with unhealthy affective responsiveness associated with higher levels of general dissatisfaction. Results from the second regression indicated only affective responsiveness predicted social and personal anxiety, R2 = .230, R2adj = .220, F(1, 78) = 23.28, p b .001, with unhealthy affective responsiveness associated with higher levels of social and personal anxiety. Results from the third regression indicated that none of the family functioning variables significantly predicted perfectionism. Results from the fourth regression indicated only general functioning predicted adolescent problems, R2 = .064, R2adj = .052, F(1, 77) = 35.38, p b .05, with unhealthy general functioning associated with higher levels of adolescent problems. Results from the fifth regression indicated that none of the family functioning variables significantly predicted weight control (Table 1). 4. Discussion Results indicated that only affective responsiveness and general family functioning were predictive of any of the risk factors for developing eating disorders. Unhealthy levels of affective responsiveness were related to both general dissatisfaction and social and personal anxiety. In addition, unhealthy general family functioning was predictive of adolescent problems, but none of the predictors related significantly to perfectionism or weight control. These results appear to correspond to those of Felker and Stivers (1994) who found that family expressiveness was the only factor of family environment that correlated with risk of eating disorders in adolescents. However, given the extensive literature indicating relationships among multiple dimensions of family functioning and eating disordered behavior, the lack of relationship among problem-solving, communication, roles, affective involvement, or behavior control with any of the risk factors for eating disorders was unexpected. The main limitation of this study is that it relied on participants' selfreport. In addition, since the sample used in this study was primarily Caucasian and exclusively young women, it is possible these results do not generalize to other groups. Future research should aim to establish the generalizability of these results with other populations, investigate the mechanisms of these associations, and ultimately identify treatment interventions based on those findings. Role of Funding Sources There was no funding provided for this study.
Table 1 Coefficients for model variables predicting Eating Disorder Risk Factors. Risk factor
Predictor variable
B
B
t
p
General dissatisfaction Social/Personal anxiety Perfectionism Adolescent problems Weight control
Affective responsiveness Affective responsiveness N/A General functioning N/A
6.261 4.344 – .995 –
.559 .479 – .253 –
5.960 4.825 – 2.290 –
.000 .000 – .025 –
Contributors Lyke designed the study and conducted the statistical analysis. Matsen conducted literature review and wrote the introduction. Both authors contributed to and approved the final manuscript.
Conflict of Interest Both authors declare that they have no conflicts of interest.
J. Lyke, J. Matsen / Eating Behaviors 14 (2013) 497–499
References Baylan, G., Erol, A., & Kilicoglu, A. (2009). Predictors of anorectic and bulimic symptoms in adolescent girls. Bulletin of Clinical Psychopharmacology, 19(4), 407–413. Butler, N., Newton, T., & Slade, P. (1988). Validation of a computerized version of the SCANS questionnaire. The International Journal of Eating Disorders, 8(2), 239–241. Cunha, A., Relvas, A., & Soares, I. (2009). Anorexia nervosa and family relationships: Perceived family functioning, coping strategies, beliefs, and attachment to parents and peers. International Journal of Clinical and Health Psychology, 9(2), 229–240. Epstein, N.B., Baldwin, L. M., & Bishop, D. S. (1983). The McMaster Family Assessment Device. Journal of Marital and Family Therapy, 9, 171–180. Felker, K. R., & Stivers, C. (1994). The relationship of gender and family environment to eating disorder risk in adolescents. Adolescence, 29(16), 821–834. Kabacoff, R. I., Miller, I. W., Bishop, D. S., Epstein, N.B., & Keitner, G. I. (1990). A psychometric study of the McMaster Family Assessment Device in psychiatric, medical, and nonclinical samples. Journal of Family Psychology, 3(4), 431–439. Kugu, N., Akyuz, G., Dogan, O., Ersan, E., & Izgic, F. (2006). The prevalence of eating disorders among university students and the relationship with some individual characteristics. The Australian and New Zealand journal of psychiatry, 40(2), 129–135. Lattimore, P. J., Wagner, H. L., & Gowers, S. (2000). Conflict avoidance in anorexia nervosa: An observational study of mothers and daughters. European Eating Disorders Review, 8, 355–368. McGrane, D., & Carr, A. (2002). Young women at risk for eating disorders: Perceived family dysfunction and parental psychological problems. Contemporary Family Therapy, 24(2), 385–395.
499
Miller, I. W., Epstein, N.B., Bishop, D. S., & Keitner, G. I. (1985). The McMaster Family assessment Device: Reliability and validity. Journal of Marital and Family Therapy, 11(4), 345–356. Minuchin, S., Rosman, B.L., & Baker, L. (1978). Psychosomatic families. Cambridge: Harvard University Press. North, C., Gowers, S., & Byram, V. (1997). Family functioning and life events in the outcome of adolescent anorexia nervosa. The British Journal of Psychiatry, 171, 545–549. Ridenour, T. A., Daley, J. G., & Reich, W. (1999). Factor analyses of the Family Assessment Device. Family Process, 38, 497–510. Slade, P. D., & Dewey, M. E. (1986). Development and preliminary validation of SCANS: A screening instrument for identifying individuals at risk of developing anorexia and bulimia nervosa. The International Journal of Eating Disorders, 5(3), 517–538. Steiger, H., Liquornik, K., Chapman, J., & Hussein, N. (1991). Personality and family disturbances in eating disorder patients; Comparison of “restricters” and “purgers” to normal controls. The International Journal of Eating Disorders, 10, 501–512. Strober, M., Freeman, R., & Morrell, W. (1997). The long-term course of severe anorexia nervosa in adolescents: Survival analysis of recovery, relapse, and outcome predictors over 10–15 years in a prospective study. The International Journal of Eating Disorders, 22, 339–360. Waller, G., Calam, R., & Slade, P. (1989). Eating disorders and family interaction. The British Journal of Clinical Psychology, 28, 285–286. Wewetzer, C., Deimel, W., Herpertz-Dahlmann, B., Mattejat, F., & Remschmidt, H. (1996). Follow-up investigation of family relations in patients with anorexia nervosa. European Child & Adolescent Psychiatry, 5, 18–24.
