RESEARCH ARTICLE

Mother–Daughter Coping and Disordered Eating Eleni Lantzouni1,2,3*, Molly Havnen Cox4, Ann Salvator5 & Ross D. Crosby6,7 1

Department of Pediatrics, Children’s Hospital Medical Center of Akron, Akron, OH, USA Department of Pediatrics, Children’s Hospital of Philadelphia, Philadelphia, PA, USA 3 Perelman School of Medicine, University of Pennsylvania, Philadelphia, PA, USA 4 The University of Akron, Akron, OH, USA 5 Akron General Medical Center, Akron, OH, USA 6 Neuropsychiatric Research Institute, Fargo, ND, USA 7 School of Medicine and Health Sciences, University of North Dakota, Fargo, ND, USA 2

Abstract This study explores whether the coping style of teenage girls with and without an eating disorder is similar to that of their mothers’ (biological and adoptive), and whether teens with disordered eating utilize more maladaptive coping compared with those without. Eating disorder was diagnosed using the Diagnostic and Statistical Manual of Mental Disorders, Fourth Edition, Text Revision criteria, and the Coping Inventory for Stressful Situations was administered to distinguish the coping style of the participants. Our findings suggest that daughters coped very similarly to their mothers in either group. Contrary to previous studies, our sample of teenage girls with eating disorders as well as their mothers utilized less frequently the avoidance–distraction coping compared with the girls without eating disorders and their mothers. These findings reinforce the importance for family involvement and for simultaneous focus on intrapersonal and interpersonal maintenance factors during eating disorder treatment. Copyright © 2015 John Wiley & Sons, Ltd and Eating Disorders Association. Keywords anorexia nervosa; coping; disordered eating *Correspondence Eleni Lantzouni, MD. Division of Adolescent Medicine, Department of Pediatrics, Children’s Hospital of Philadelphia. 11NW Room 14. 34th and Civic Center Boulevard. Philadelphia, PA 19104, USA. Phone: 267-426-3931 (work) 330 696 1960 (cell) Fax: 215 590 4708. Email: [email protected] Note: Children’s Hospital Medical Center of Akron was my previous affiliation where the study took place. Published online 19 January 2015 in Wiley Online Library (wileyonlinelibrary.com) DOI: 10.1002/erv.2343

Introduction Earlier as well as more recent studies have linked eating disorders (EDs) to maladaptive coping. In earlier studies, it is unclear whether coping plays a predisposing or maintenance role. For example, studies of family function suggest that disordered eating during adolescence is associated with adolescent–parent conflict, parental overprotection and restricted emotional expression by both adolescents and parents (Archibald, Linver, Graber, & Brooks-Gunn, 2002; Turner, Rose, & Cooper, 2005). In addition, studies of mothers and daughters suggest that EDs in daughters are associated with body dissatisfaction in mothers (Benedikt, Wertheim, & Love, 1998; Espina, de Alda, & Ortego, 2003). Furthermore, coping-related studies suggest that women with EDs utilize more emotional and avoidance coping (Garcia-Grau, Fuste, Miro, Saldana, & Bados, 2002; Koff & Sangani, 1997), and they are less effective in their coping (Troop, Holbrey, & Treasure, 1998). Research findings during the last decade have shed some light on interpreting the connection between coping and disordered eating. The focus of current studies has clearly shifted towards identifying maintenance rather than risk factors for EDs. While 126

risk or predisposing factors remain of great interest to researchers (Hilbert et al., 2014) and crucial for development of prevention programmes, they are not as valuable in clinical practice. Researchers have recently described various theoretical models for the maintenance of EDs. These models vary depending on whether they identify interpersonal or intrapersonal elements as maintenance factors. Among the various models, the maintenance model for anorexia nervosa (AN) proposed by Schmidt and Treasure (Schmidt & Treasure, 2006) remains exemplary. This model (cognitive– interpersonal) was initially developed in 2006 and was recently updated (Treasure & Schmidt, 2013). This model is all-inclusive and incorporates both intrapersonal and interpersonal maintenance factors. The maintenance factors taken into consideration by this model include the following: (1) emotional and relational style such as harm avoidance, inhibited expression of negative emotions and anxiety; (2) cognitive style such as rigidity in thinking, perfectionism and detail-focused; (3) interpersonal components such as response of close others, expressed emotion and accommodation from carers; and (4) valued nature of AN. The interpersonal model of maintenance of EDs has been validated by Goddard et al. (2011) and Goddard et al. (2013). Goddard

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suggests that carers’ expressed emotion (over involvement, criticism and hostility) in combination with enabling or accommodating behaviours maintain the illness. This model is also supported by recent studies of family function. Such studies reveal that families with an eating disorder (ED) sufferer tend to have high caregiver burden, higher expressed emotion for AN and higher levels of criticism for bulimia nervosa (BN) (Anastasiadou, Medina-Pradas, Sepulveda, & Treasure, 2014; Duclos et al., 2013; Sepulveda et al., 2010). Sepulveda indicates that parents can take complimentary roles within the family; one parent can be overprotective and the other avoidant (Sepulveda et al., 2010). Furthermore, mothers tend to be more anxious, emotionally over-involved and at a higher level of distress, whereas fathers, more critical. This observed difference between parents could be attributed to mothers usually being the main carers and fathers having difficulty understanding the ED (Goddard et al., 2013; Jacobs et al., 2009; Kyriacou, Treasure, & Schmidt, 2008; Raenker et al., 2013; Whitney, Currin, Murray, & Treasure, 2012). On the other hand, Haynos and Fruzzetti’s comprehensive transactional model of emotion dysregulation in AN is a noteworthy example among models focusing on intrapersonal maintenance factors (Haynos & Fruzzetti, 2011). This model proposes that inherent deficits in emotion regulation, distress tolerance and behavioural regulation impede recovery from AN. This view is supported by an array of scholars. Engel et al. (2013) indicate that negative affect is associated with more disordered behaviours. Consequently, other researchers suggest that patients with EDs have inhibited expression of negative emotions (Geller, Cockell, Hewitt, Goldner, & Flett, 2000), difficulty tolerating distress (Hambrook et al., 2011) and higher levels of perfectionism (Holland, Bodell, & Keel, 2013). To conclude, the observed deficits in coping skills described in earlier studies (Garcia-Grau et al., 2002; Koff & Sangani, 1997; Troop et al., 1998) seem closely interrelated to the emotion dysregulation and distress intolerance described in more recent studies (Geller et al., 2000; Hambrook et al., 2011). According to the transactional model of stress and coping (Wenzel, Glanz, & Lerman, 2008), people encounter two steps while facing a stressful situation. The first step is to evaluate the significance and potential threat of the situation. The second, to assess the options and tools they possess to deal with the situation. With the stress and coping model in mind, the intrapersonal and interpersonal maintenance factors could be viewed as coping deficits in both patients and carers. Conclusively, there are no studies to our knowledge that compare the coping behaviours of adolescent daughters with EDs to those of their carers, in particular, their mothers who tend to be the main carers. The aim of this study is to explore the within-dyad correlation of mother–daughter coping behaviours in a sample of adolescent females with and without EDs.

Methods Design The study was designed as a cross-sectional survey of a hospitalbased outpatient clinic sample. The study protocol was approved by the institutional review board of the hospital and affiliated university. Daughters signed informed assent if younger than 18 years and informed consent if 18 years and older. Mothers signed

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informed consent for the participation of daughters younger than 18 years and for their own participation. Participants Eligible participants consisted of females aged 13 through 18 years presenting to the Adolescent Health Center at a Midwest Children’s Hospital for an initial or return visit who had no chronic conditions other than eating disorders and who were accompanied by their mothers. The Adolescent Health Center offers specialty and primary care for teenagers; the female teenagers with ED were recruited at the specialty clinic and the female teenagers without ED at the primary care clinic. Enrollment required the participation of both daughter and mother, and inclusion required the completion of study instruments by both daughter and mother. Overall, we included 29 daughters with ED (EDD) and their mothers (M EDD), and 29 daughters without ED (NEDD) and their mothers (M NEDD). Procedures Eating disorder diagnosis was established by medical personnel with expertise in childhood eating disorders using the DSM-IVTR criteria and included the diagnoses of AN, BN and ED Not Otherwise Specified (ED NOS). Additional data collected included measured patient height and weight and self-report for mothers’ height, weight and age. Patients’ and mothers’ body mass index (BMI) were calculated. The daughters in both groups completed the Eating Attitudes Test-26 (EAT-26) (Garner, Olmsted, Bohr, & Garfinkel, 1982) and the Coping Inventory for Stressful Situations (CISS), adolescent version (Endler & Parker, 1999). These instruments have been validated for individuals > 13 years of age (Garner et al., 1982). The daughters’ weight and height were objective measurements from that visit. Weight was measured in gown and height with a wall mounted stadiometer. The mothers in both groups completed a demographics form (Table 1) and the CISS, adult version (Endler & Parker, 1999). Measures The EAT-26 is a self-report inventory that measures eating attitudes related to ED. The 26 items of the EAT-26 are scored on a six-point Likert scale that ranges from ‘always’ to ‘never’. The total score range is 0–78, with higher scores indicating greater pathology. A score of 20 is the recommended cut-off for screening for ED (Garner et al., 1982), Cronbach’s coefficient alpha was 0.83 (Koslowsky et al., 1992). EAT-26 was primarily used to screen for potential ED in the group of patients without ED diagnosis. EAT-26 is easily administered and interpreted. The CISS measures coping skills used when individuals are faced with stressful situations (Endler & Parker, 1999). Using a five-point Likert scale that ranges from ‘Not at All’ to ‘Very Much’, both the adult and adolescent versions divide coping into three basic scales: task, emotion and avoidance-oriented coping. Avoidance is further broken down into distraction and social diversion subscales. The CISS consists of 58 questions; 16 questions towards each coping scale. Coefficient alphas range from 0.87 to 0.92 on the task scale, from 0.82 to 0.90 on the emotion, 0.76 to 0.85 on the avoidance scale and 0.75 to 0.81 on the subscales of distraction and social diversion, indicating good internal

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consistency reliability (Endler & Parker, 1999). In this study, Cronbach’s alpha for task was 0.896, for emotion 0.843 and for avoidance 0.839. For the avoidance subscales, Cronbach’s alpha for distraction was 0.735 and for social diversion 0.835. The completed CISS forms were scored by a psychologist. The raw scores in all subscales were converted into standard T scores according to the manual, with a mean of 50 and a standard deviation of 10. CISS has an adolescent as well as an adult version; therefore, a suitable instrument for this study that allowed comparisons of coping between mothers and daughters.

BMI and household income (Table 1). The primary outcome variable for this study was the CISS subscale scores on task, emotion and avoidance-oriented coping. A multilevel mixedeffects model was used to compare CISS scores. Mothers and daughters were nested within family pairs to take into account familial covariance. Models included a random intercept and a fixed effect for source, represented by four levels: EDD, M EDD, NEDD and M NEDD. Pairwise comparisons were based upon four a priori contrasts of interest: EDD versus M EDD; NEDD versus M NEDD; EDD versus NEDD; and M EDD versus M NEDD.

Hypothesis Our specific hypotheses were as follows: (1) daughters utilize similar coping mechanisms to their mothers, and (2) EDD utilize more frequently maladaptive (avoidance or emotional) coping compared with NEDD. While our hypothesis was directional, the significance test was a nondirectional test, allowing for the possibility of unanticipated findings.

Data analysis and statistics Descriptive statistics were used to describe study subject demographics including mothers’ and daughters’ age, weight, Table 1 Patient demographics

Number of mothers Number of daughters Mother’s age Daughter’s age % Family income > $75 000 % Mother graduated high school % Caucasian a % Mothers no health problems b % Mother is biological parent Mothers BMI Age difference mom & daughter Daughter’s BMI Daughter’s EAT score

EDD

NEDD

p-value

29 29 44.4 ± 5.8 15.9 ± 1.5 13 (46%) 19 (76%) 28 (96%) 20 (68%) 27 (93%) 25.4 ± 5.1 28.9 ± 5.5 18.9 ± 2.3 19. 5 ± 17.7

29 29 41.6 ± 5.9 15.6 ± 1.4 5 (17%) 9 (37%) 20 (69%) 16 (55%) 29 (100%) 28.2 ± 7.6 26.3 ± 5.6 23.7 ± 4.7 8.2 ± 6.2

0.09 0.31 0.02 0.006 0.003 0.02 0.35 0.3 0.08 0.0001 0.02

*This was determined by two questions ‘Do you have any health problems lasting more than 3 months?’ If the answer was ‘Yes, please describe’ and ‘List any medications that you are currently taking’ † Two mothers were adoptive. Both daughters were adopted at a very young age. BMI, body mass index; EDD, daughters with eating disorder; NEDD, daughters without eating disorder. Data are presented as the mean ± SD.

Results A total of 58 mother/daughter dyads (N = 116) were enrolled in this study. Across both groups, the mothers were similar with respect to age and BMI, while the daughters were similar with respect to age. As expected, EDD had significantly lower BMI (18.9 kg/m2) than the NEDD (23.7 kg/m2). Notable differences between the two sets of mothers included a higher percentage of M EDD being Caucasian and having graduated from high school (Table 1). One adolescent participant in the non-ED group, who scored high on the EAT-26, was excluded from study due to the possibility of actually having an undiagnosed ED. A multilevel mixed-effects model analysis was utilized to compare the scores on the three scales of the CISS (i.e., task, emotion, and avoidance) and the scores on the two subscales of avoidance (distraction and social drive) between the 4 groups (Table 2 & 3). No statistically significant difference was observed between the four groups concerning task-oriented coping. However, the daughters in both groups scored higher on task-oriented coping than their mothers. Similarly, there was no significant difference between the two groups of mothers and daughters in regards to emotion Table 3 P-values of pairwise comparisons in CISS scores Task Emotion Avoidance Distraction Social diversion EDD with M EDD NEDD with M NEDD EDD with NEDD M EDD with M NEDD

0.074 0.161 0.416 0.67

0.463 0.044 0.395 0.675

0.446 0.41 0.021 0.024

0.413 0.378 0.006 0.007

0.736 0.448 0.084 0.422

CISS, Coping Inventory for Stressful Situations; EDD, daughters with eating disorder; NEDD, daughters without eating disorder; M EDD, mothers of daughters with eating disorder; M NEDD, mothers of daughters without eating disorder

Table 2 CISS scores in each group Task oriented

EDD M EDD NEDD M NEDD

Emotion oriented

Avoidance total

Distraction

Social diversion

Mean

95% CI

Mean

95% CI

Mean

95% CI

Mean

95% CI

Mean

95% CI

52.8 48.1 50.6 47

49.1–56.6 44.4–51.9 46.9–54.4 43.3–50.7

49 50.8 46.7 52

45.3–52.7 47.2–54.6 43.1–50.5 48.3–55.7

48.2 46.5 54.1 52.3

44.7–51.8 43–50 50.6–57.7 48.8–55.9

47.4 45.6 54.1 52.2

44.1–50.8 42.3–49 50.8–57.5 48.9–55.6

46.8 47.6 51.8 50

42.8–50.9 43.7–51.7 47.8–55.9 46–54

CISS, Coping Inventory for Stressful Situations; CI, confidence interval; EDD, daughters with eating disorder; NEDD, daughters without eating disorder; M EDD, mothers of daughters with eating disorder; M NEDD, Mothers of daughters without eating disorder.

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oriented coping. However, M NEDD used more emotional coping (mean = 52) than their daughters (46.7), p = 0.044 (Table 2 and 3). Pertaining to avoidance-oriented coping, mothers in each group scored similarly to their daughters. However, M EDD used less avoidance coping (46.5) than M NEDD (52.3), p = 0.02. Similarly, EDD used less avoidance coping (48.2) than NEDD (54.1), p = 0.02 (Table 2 and 3). When comparing avoidance subscales, it was in distraction that the difference was observed. M EDD used less distraction (mean = 45.6) than M NEDD (mean = 52.2), p = 0.007, and EDD used significantly less distraction (mean = 47.4) than NEDD (mean = 54.1), p = 0.006. The four groups did not differ significantly on the social diversion subscale. Mothers in each group scored similarly on social diversion subscale with their daughters. Although EDD used less social diversion (46.8) than NEDD (51.8), the difference did not reach statistical significance, p = 0.08 (Table 2 and 3). Because two of the questions on CISS (12 and 18) refer to treating yourself to your favourite food or going out to eat, the answers on these questions were compared between the two groups of mothers and daughters. EDD were less likely to treat themselves with their favourite food (21%) compared with NEDD (52%), p = 0.01 (question 12). There was no difference on how the mothers answered both of those questions and on how daughters answered question 18 (going out to eat).

Discussion This study explores the within-dyad correlation of mother– daughter coping behaviours in adolescent females with and without eating disorders. Our findings support the hypothesis that daughters cope very similarly to their mothers and are in accordance with existing literature suggesting that daughters are strongly influenced by mothers’ modelling and interaction with the world around them (Ogden & Steward, 2000; Pike & Rodin, 1991). Coping is a learned evolving behaviour that leads to growth and adjustment. Coping also interacts with personality and one’s stress managing experience. According to Skinner (Skinner & Edge, 1998), parents provide the psychological resources, actively participate in solving problems and provide the model of a dyadic system of interaction. In addition, social interactions at school also could model adaptive coping (Zimmer-Gembeck & Locke, 2007). It is important to note, however, that this study did not explore mothers’ eating attitudes. Contrary to our anticipation, EDD and their mothers in our study sample scored higher on task-oriented coping. These findings are in conflict with the results of Espina (Espina et al., 2003) that indicate that M EDD interact with their environments in a less healthy manner (avoidance-oriented). Our results also contradict those of Soukup (Soukup, Beiler, & Terrell, 1990), that indicate that hospitalized women with ED exhibit mostly avoidance coping despite scoring high in problem solving confidence. Researchers (McWilliams, Cox, & Enns, 2003) have asserted that task-oriented coping is the most adaptive form of coping and is negatively associated with psychological distress and depression, while emotion and avoidance-oriented coping have been found to correlate highly with depression (McWilliams et al., 2003) and disordered eating (Koff & Sangani, 1997). On the other

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hand, according to Lazarus (Lazarus & Folkman, 1984), coping strategies should be considered under the circumstances they occur, and it is not wise to prejudge them as adaptive or maladaptive. One possible explanation for our contradicting findings is that teens with ED might utilize different coping skills to deal with tasks (education, work and school) and with relationships (interpersonal). It is unclear how coping is linked to an eating disorder. According to Connan’s (Connan, Campbell, Katzman, Lightman, & Treasure, 2003) neurodevelopmental model for AN, genetic factors interact early in life to modify hypothalamic-pituitaryadrenal axis regulation, resulting in poorly regulated stress responses. Thus, the vulnerable to AN individual enters adolescence with a limited ability to cope with stress. In addition, precipitating and predisposing factors for AN are likely to be adding to the hypothalamic-pituitary-adrenal axis dysregulation and poor coping style. For instance, in exploration of risk factors, a recent study by Hilbert et al. (2014)) indicates that dieting is the only consistent onset symptom along the spectrum of EDs. In the same study likewise, perfectionism was the only consistent predisposing factor for AN. Searching for risk factors continues to remain appealing for the development of prevention programmes. However in clinical practice, focusing on maintenance factors is more pragmatic and conducive to recovery. Furthermore, the recent literature is enriched with theoretical models on the maintenance of ED and asserts that coping plays rather a maintenance role. These models were aforementioned in the introduction section. However, revisiting them briefly could explain some of our study findings. According to Schmidt and Treasure’s (Schmidt & Treasure, 2006; Treasure & Schmidt, 2013) model on the maintenance of AN, an emotional parental reaction to the child’s ED might worsen and delay recovery from the ED. In addition to interpersonal factors, this model also incorporates intrapersonal factors. Among the later, noteworthy are the obsessive–compulsive personality and cognitive rigidity. These traits indicate limited ability to employ distraction skills and therefore seem to be in accordance with our findings. The cognitive inflexibility and focus on details subsequently interfere with the individual’s ability to view the bigger picture, relax and tolerate distress (Wonderlich et al., 2008). The Integrated Cognitive Affect model on maintenance of BN describes negative emotion as a mediator between self-discrepancy (when individual views self far different from ideal self) and maladaptive coping skills. Similarly, Goddard et al. (2011) indicate that carers of ED patients have high expressed emotion, self-blame and tendency to neglect their own self-care needs. These findings illustrate lack of adaptive coping by the carers. In our study, M EDD underutilize distraction skills; therefore, one could suggest that under certain circumstances (illness of a loved one), distraction could serve as an adaptive mechanism that allows for self-care and prevention of emotional burn out. Lastly, models focusing on intrapersonal factors such as Haynos and Fruzzetti’s (2011) propose that deficits in emotion regulation and distress tolerance contribute to ED maintenance. Our findings suggest that EDD under-utilize distraction skills; therefore, one could assert that under stressful circumstances, distraction skills could potentially play an adaptive role and facilitate distress tolerance.

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It is also unclear how potential mediating factors such as perfectionism and negative affect interplay between coping and acquisition or maintenance of an ED. According to Bardone-Cone (Bardone-Cone, Sturm, Lawson, Robinson, & Smith, 2010), achievement striving (adaptive perfectionism) is actually maladaptive when it comes to ED. According to Dunkley (Dunkley, Zuroff, & Blankstein, 2003), perfectionism and avoidance coping brings low life satisfaction. Perfectionistic concerns (Stoeber & Janssen, 2011) predict less frequent use of acceptance and active coping and more frequent use of self-blame coping. A recent model suggested by Dunkley (Dunkley, Ma, Lee, Preacher, & Zuroff, 2014) is worth noting; disengagement (avoidance) coping patterns trigger negative affect on a daily basis. However, perfectionism and especially self-criticism is a maintenance factor for a continued negative affect. In concluding, it appears that perfectionism and self-criticism possibly play a mediating role between coping, negative affect and life satisfaction, which subsequently connect to an ED. The demographic differences observed in our two groups of study subjects (Table 1) are consistent with extant literature that risk of acquisition of ED is increased with higher socioeconomic status (Lindberg & Hjern, 2003), higher level of education (Ahren, Chiesa, af Klinteberg, & Koupil, 2012; Ahren-Moonga, Silverwood, af Klinteberg, & Koupil, 2009) and Caucasian race (Sue & Sue, 2003). There are limited research data comparing coping style as a function of race. In a study comparing coping in male athletes, Anshel (Anshel, Kang, & Miesner, 2010; Anshel, Sutarso, & Jubenville, 2009) found that Caucasian athletes used more approachbehavioural coping such as ‘I discussed the problem with others’ compared with African American male athletes that appear to use more avoidance coping such as ‘I prayed for help’. Belgrave & Allison (2006) and Boyd-Franklin (2003) also indicate the use of spirituality as a factor to cope with stressful events in African Americans. However, differences in coping due to spirituality could not be captured in our study because the CISS avoidance subscale lacks questions related to spirituality. Clearly, additional research regarding these understudied factors is warranted. Limitations A larger sample size would have bolstered the generalizability of the results. The mothers’ BMI scores were based on self-reports that might differ from actually measured weights and heights. Methodological limitations of this study include the demographic differences (family income, Caucasian, percentage of mothers who graduated high school and having health problems) between families with EDD and NEDD. Utilizing methods to assess coping at the time it occurs, is more accurate due to reduced bias associated with retrospective recall. Examples of such methodologies include diary methods (Dunkley et al., 2003) and Ecological Momentary Assessment (EMA) (Engel et al., 2013; Goldschmidt et al., 2014; Wonderlich et al., 2014). EMA is a technique that involves data collection in a participant’s natural environment in the moment when emotional experiences and behaviours occur (Smyth et al., 2001). Another methodology of interest, which has been increasingly used during the last decade, is implicit 130

measures of association (Roefs et al., 2011). Implicit assessments explore associations between subconscious beliefs and a disorder. Implicit assessment procedures in the ED field have been used to assess body image dissatisfaction and internalization of thin ideal (Ahern, Bennett, & Hetherington, 2008; Juarascio et al., 2011) as well as self-esteem (Cockerham, Stopa, Bell, & Gregg, 2009; Hoffmeister, Teige-Mocigemba, Blechert, Klauer, & Tuschen-Caffier, 2010). Another arising possibility is whether the existing instruments of coping capture coping differences in the young generation that relies immensely on social media and the internet as a coping venue. Developing coping inventories with questions more suitable to capture the coping mechanisms that the younger generation might be using (social media and internet) should be considered.

Conclusions Coping is crucial for dealing with stress and adjusting to change. Coping is influenced by genes, personality characteristics and environment, and especially by parents who provide a model for development of problem solving skills. This further underscores the need for family involvement in treating teens with ED. Educating patients and their families about dealing more effectively with stress and developing resilience is a crucial step in overcoming ED and other chronic illnesses. Surprisingly in this study, teenage women with ED utilized less avoidance–distraction mechanisms. We speculate that the ability to distract oneself under certain circumstances could be a protective mechanism that leads to distress tolerance. New updated methods (e.g. EMA, implicit) for evaluating coping are needed. The proposed theoretical models on the maintenance of ED could be further explored, tested and improved. Developing treatment approaches that focus on improving coping in both carers and patients simultaneously could be more advantageous than focusing either on interpersonal or intrapersonal maintenance factors alone. The findings of this study could be further tested and applied in developing programmes to teach distraction skills, distress tolerance and self-care in patients with ED and their families. The interference between coping, perfectionistic concerns and negative affect should be further studied.

Acknowledgements Many thanks to Michael Reed MD, Gail Slap MD and Rebecka Peebles MD for their constructive feedback and encouragement. Many thanks to Elyse Salek for her help with the references and technical support through the submission process. I also want to express my gratitude to James Fitzgibbon MD, my mentor and chief of the Adolescent Medicine Division at Children’s Hospital Medical Center of Akron where the study took place and to Robert Schwartz, Molly’s advisor who provided guidance at the early stages of this study. At last, I am grateful to the Academy of Eating Disorders that matched me with my research mentor Ross Crosby whose guidance helped me better interpret the results and finalize this paper.

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