REVIEW

Parents and Prevention: A Systematic Review of Interventions Involving Parents that Aim to Prevent Body Dissatisfaction or Eating Disorders Laura M. Hart, PhD* Chelsea Cornell, BA/BBSc (Hons) Stephanie R. Damiano, PhD Susan J. Paxton, PhD

ABSTRACT Objective: To systematically review the literature on interventions involving parents that aim to prevent body dissatisfaction or eating disorders in children, and provide directions for future research by highlighting current gaps. Method: The literature was searched for articles using key concepts: parents, prevention and eating disorders or disordered eating or body dissatisfaction. All English language publications between 1992 and 2013 were searched across a range of academic databases. Studies were reviewed if they: (i) delivered an intervention designed to reduce eating disorders or body dissatisfaction or their risk factors, in children or adolescents; (ii) provided some intervention component for parents; and (iii) included some outcome measure of intervention effectiveness on disordered eating or body dissatisfaction. A scoring matrix based on the Critical Appraisal Skills Program (CASP) screening questions was used to assess each study’s sample representativeness, relevance and data quality.

Introduction Parents are known to shape the development of a wide range of risk and protective factors for body dissatisfaction and eating disorders in their children.1,2 For example, parents are salient role models who communicate attitudes and display behaviors relating to food, body weight, and shape, in front of their children.3,4 Parents can also influence their child through direct verbal messages about a child’s appearance and eating, or through encouraging a child to change their diet or weightAccepted 1 April 2014 Additional Supporting Information may be found in the online version of this article. *Correspondence to: Laura M. Hart; School of Psychological Science, La Trobe University, Melbourne, Australia. E-mail: [email protected] School of Psychological Science, La Trobe University, Melbourne, Australia Published online 5 May 2014 in Wiley Online Library (wileyonlinelibrary.com). DOI: 10.1002/eat.22284 C 2014 Wiley Periodicals, Inc. V

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Results: From 647 novel records uncovered by the search, 20 separate studies met inclusion criteria. The CASP scoring matrix revealed eight studies provided no relevant data, four relevant and eight highly relevant data on the effects of involving parents in prevention programs. Two of four high-quality studies reported that parental involvement significantly improved child outcomes on measures of body dissatisfaction or disordered eating. Discussion: Although a greater focus on engaging and retaining parents is needed, this review demonstrates that a small number of prevention studies with parents have led to significant reductions in risk of body image and eating problems, and future research is indicated. C 2014 Wiley Periodicals, Inc. V Keywords: parent; prevention; eating disorders; body dissatisfaction; systematic review (Int J Eat Disord 2015; 48:157–169)

control behaviors.5–7 A review by Rodgers and Chabrol1 found that parental focus on the importance of appearance and weight can increase body shape and weight concerns among their children, and that this effect is particularly strong when parents directly criticize their child, or actively encourage them to lose weight. In addition to direct criticism, parent modeling of dieting and weight-control behaviors, such as restriction and abstention, was also found to significantly increase a child’s dissatisfaction with their weight or shape and likelihood of engaging in dieting and bulimia nervosa-type behaviors.8 Parents though, are not the only important sources of influence on the development of body dissatisfaction and disordered eating. Sources of sociocultural pressure are numerous and, in addition to parents, peers, and media are particularly strong influences.1,9–11 Peers, for example, can exert influence on a child’s body image and eating habits through fat talk, pressure to diet and 157

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appearance-based teasing.12–14 Through consistent display of unattainable idealized images, exposure to media can result in elevated body dissatisfaction.15 Nevertheless, parents play a unique role in shaping the development of eating patterns and body confidence, partly because parents can impact the relationship between their children, peers and media, especially while the children are young. For example, parents could help develop resilience to peer comments or pressure to value dieting, weightloss, and the thin-ideal, by encouraging value-based judgment rather than appearance-based judgment in their child.16 In addition, parents can limit a child’s exposure to harmful messages about the importance of thinness in the media, by limiting screen time and developing critical media viewing, or “media literacy.”17,18 Importantly, parents can also counteract the impact of peers and media by modeling protective behaviors for their children; by displaying positive body image and healthy eating habits, and avoiding reinforcement of appearance stereotypes.1,19,20 Given their important role in shaping child eating and body image, eating disorder researchers have been calling for parental involvement in prevention programs from as early as 1996.21 Primary prevention of eating disorders aims to reduce the incidence of clinical eating disorders. This is achieved through reduction of risk factors and optimization of protective factors. Ecological approaches to eating disorder prevention are those that aim to change the complex environment within which the developing child is located; the family, school, and peer group contexts and the interactions between these.22 For school-aged children, ecological prevention programs have targeted school communities by providing intervention modules for entire student and teacher bodies.23 However, despite the important role of parents in providing context for eating and appearance-related behaviors, many school-based ecological interventions have not provided intervention components for parents.24,25 For children in the pre-school years, when the family of origin is the most important source of information about healthy body image and eating patterns, arguably parents should become the primary focus of prevention efforts. Yet, previous reviews of eating disorder prevention research have not reported on programs with parents of pre-school children.23,26 Thus, there is an important gap in the research and review literature on the value of including parents in prevention interventions for body dissatisfaction and eating disorders. For the field to heed the call and effectively involve parents, we must first learn from earlier 158

efforts by examining the successes of previous published trials.27 To consolidate current knowledge and provide directions for future program development and evaluation research, the purpose of this study was to systematically review the literature on body dissatisfaction and eating disorders prevention programs involving parents.

Method This review followed the PRIMSA guidelines for conducting and reporting systematic reviews.28, 29 Data Sources CSA Psyclnfo, ISI Medline, and Scopus databases were searched for eligible studies published in English between January 1992 and October 2013. The first search was conducted in April 2012 and updated in October 2013. Two searches in each database were conducted; a title/abstract/keyword search and a descriptor search. The first search was based on searching the title, abstract and keyword fields for a specified combination of terms that described the concepts of (1) parents, (2) prevention, and (3) body dissatisfaction or eating disorders. The search strategy was therefore: [parent* AND prevent* AND (“disordered eating” or binge or purge or “eating disorder*”) OR {(body or “body image” or shape or weight) and (concern or preoccup* or dissatf*)}]. The wildcard function “*” was used to search multiple suffixes of the same term. The second, descriptor search used subject headings or key word descriptors assigned by individual databases. Database thesauri were used to select appropriate descriptors for the concepts of parenting, prevention and body dissatisfaction or eating disorders. The specific protocol for these searches can be provided upon request. In addition, the reference sections of relevant studies identified in the searches were manually scanned for other relevant studies. The search strategy was checked for accuracy by ensuring a priori known relevant articles were selected. Study Selection Resulting studies were inspected by two authors (LH and CC) to assess for the following inclusion criteria: (1) Delivery of a prevention program designed to reduce body dissatisfaction or eating disorder symptoms or risk factors in children. Papers that described a protocol for development of a program but did not implement or evaluate it, were excluded. There were no restrictions on child participant age and hence adolescents were also included. (2) Some component of program delivery specifically targeted to parents. Studies that involved parents in measurement of variables without providing program delivery, (i.e., completing parent-report questionnaires International Journal of Eating Disorders 48:2 157–169 2015

PARENTS AND PREVENTION

about child behavior), were excluded. (3) Implementation and reporting of an outcome measure to evaluate the prevention program. Outcome measures could include those assessing child body image, child eating pathology or eating behaviors, or parental behavior impacting on child eating or body image, for example, parental feeding behaviors. Outcome measures could be completed by the parent, the child or both. Where reporting of program content, delivery design, or use of outcome measure was inadequate for review, authors were contacted for further details. If authors could not be contacted or sufficient detail provided, studies were excluded. Data Extraction Data from the reviewed studies were extracted by one author (LH) using a data extraction template and codebook based on the principles outlined by Elwood.30 The data extracted was used to describe, compare, and assess the studies on elements such as evaluation design, child outcome measures, sample characteristics, and statistical analyses. A full copy of the extraction template and codebook can be provided upon request. Study Quality To assess the quality of eligible studies, two authors (LH and SD) scored each for sample representativeness, relevance, and data quality, according to the aims of the current research. To do this, a scoring matrix adapted from the Critical Appraisal Skills Program (CASP) screening questions for cohort studies31 was used. The original 11-item CASP tool was developed to critically appraise the quality of cohort studies and involves answering a series of questions about methodological quality.32 The shortened, adapted version has previously been used in the eating disorder literature.33 Each study was scored on a scale of 0–2 points, on each CASP item, using a structured scoring protocol, with higher scores indicating higher quality. For example, on CASP item 1, Did the study evaluate a prevention intervention for ED or BD in children or adolescents using an experimental design? a study scored two points if it involved a randomizedcontrolled design with repeated measures at baseline and posttest; scored one if it used a repeated measures, uncontrolled design; and zero if it proposed an intervention but did not evaluate it. Where the authors’ score was in disagreement, the authors reviewed the data and came to a consensus on the final decision. The codebook can be provided upon request. CASP item 4 Did the study measure how effective the intervention was in helping parents positively impact on child risk for ED or BD? and CASP item 5 Was significance testing, effect sizes/confidence intervals reported for parent effect on child outcome over time?, were considered the International Journal of Eating Disorders 48:2 157–169 2015

most important items for determining the quality of data provided on the effectiveness of involving parents in prevention programs. Studies that scored two points on CASP item 4 provided the most relevant and specific data on how parents can influence child risk for body dissatisfaction and eating disorders, while studies that scored two points on CASP item 5 provided the most valid and reliable data on program effectiveness. Therefore, studies that scored two points on each of these items were considered to be the highest quality papers providing the most relevant and reliable data on how parents can be involved in prevention research.

Results Search Results

Figure 1 depicts the flow of candidate and eligible articles In total, 647 articles were subjected to a preliminary title and abstract screen. Of those, 611 articles were excluded as they clearly did not meet the three inclusion criteria. Of the remaining 31 articles, 11 were excluded because: the article reported on the same sample as a publication already included (n 5 3), the article did not present intervention evaluation data (n 5 4), the study did not include a measure relevant to body dissatisfaction or eating disorders (n 5 4). This left 20 studies included in the review. A detailed summary of these studies can be found in Table A of Supporting Information. The studies represented published and unpublished research, as well as doctoral theses. Large heterogeneity in program structure and research methodology was found across the literature. Across the studies, approximately 1,060 parents of 11,155 children, aged between 6 and 16 years were involved in a range of different evaluation and intervention programs. The sample of parents is a known underestimate, as some studies did not report how many parents received or engaged with prevention program materials. Study Quality

Table 1 shows the CASP matrix scoring for all 20 studies included in the review. Eight studies scored zero on CASP item 4, indicating that they provided no data on the effects of involving parents in prevention programs.34–41 Many of these studies included large randomized controlled trials conducted in the school setting. Although most of these studies provided quality data on how specific prevention programs could be effective in reducing eating disorder or body dissatisfaction risk in children or adolescents, they did not provide useful data about how the inclusion of parents can help 159

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FIGURE 1. Academic databases CSA Psyclnfo, ISI Medline and Scopus were searched for eligible studies published in the English language between January 1992 and October 2013. Studies needed to meet three criteria to be included in the review: 1) evaluate an intervention aimed at preventing eating disorders or body dissatisfaction or their risk factors, in children, 2) provide some program component to parents, 3) include an outcome measure relevant to assessing child body image, eating behaviors, or parental behavior impacting on child eating or body image.

prevent these problems and were therefore not considered of further relevance to this review. Four studies scored one point on CASP item 4, indicating some data were available about the effect of including parents, but they were not conclusive.42–45 Many of these studies specifically designed intervention components for parents, rather than just providing materials designed to complement a student-focused intervention. The design of their evaluation research, however, meant that specific data on how parents impacted on child outcomes were not collected, or specific analyses were inconclusive. The final eight studies scored a maximum of two points on CASP item 4, indicating data of high specificity for understanding parental effects on 160

child body dissatisfaction and eating disorders.46–53 Not all of these studies were able to recruit or retain a sufficient sample of parents to report high quality data. Two studies scored zero on CASP item 5 because they were unable to recruit sufficient sample sizes to conduct significance testing.49,53 For example, the Body Logic study by VarnardoSullivan, Zucker, Williamson, Reas, Thaw, and Netemeyer53 aimed to provide parents whose adolescent child had been found to be at-risk of a clinical eating disorder with an intensive family-based program involving separate workshops for parents and adolescents on healthy eating and promotion of positive body image. Although carefully designed through consultation with parents, and despite inclusion of 55 adolescent participants International Journal of Eating Disorders 48:2 157–169 2015

2 A range of validated measures were used across the different studies

2 EDI, WCS, EDEQ

2 Multiple different school-based studies to prevent EDs reported

2 RCT w parents and children randomized separately

2 RCT w Gymnastic clubs

1 Uncontrolled RM

2 RCT w mothers only receiving interv, daughters only completing measures

1 Controlled, nonrandomized RM

Berger (2011)34

Bruning Brown (2003)46

Buchholz (2008)42

Coller (1999)35

Corning (2010)47

Fiissel (2006)36 2 ChEAT 1 others

1 Questions about dieting behavior 2 C-DISC, EDI, BPDS

2 EAT, SATAQ

2. Child measure Did the study use an outcome measure of child risk of ED or BD?

1. Design Did the study evaluate a prevention intervention for ED or BD in children or adolescents using an experimental design?

Adaptation Explanation

2. Did the authors use an appropriate method to answer their question?

1. Did the study address a clearly focused issue?

1 Girls, 7–11 years

0 Girl scouts bw 10–12 years 0 7th–8th grade girls only 1 mothers

0 Gymnasts ranged in age but only girls, mothers only

1 Although each of the studies focused on only girls or boys in a particular age group, taken together, the data is broadly representative 0 10th grade girls only

3. Recruitment Did the inclusion criteria minimize bias and lead to generalizable results?

3. Was the cohort recruited in an acceptable way?

0 No assessment of parent effect on child outcomes. Parents offered info sessions but 0 participated

1 Comparison of parent cont and interv scores, but no assessment of parent effect on child outcome 0 No assessment of parent involvement 2 Mothers randomized to receive interv or cont while daughters completed measures

2 Subgroup analyses on students in interv comparing their parents in interv versus cont

0 No assessment of parent involvement

4. Assessment of parent effect Did the study measure how effective the intervention was in helping parents positively impact on child risk for ED or BD?

4. Was the exposure accurately measured to minimize bias?

Study quality scores based on the Critical Appraisal Skills Program (CASP) screening questions

Original CASP Question

TABLE 1.

0 Qualitative posttest only due to n 5 7 parents

0 No quantitative data analysis 2 Bw participants ANCOVAs conducted w partial g2 reported

0 No sig testing on parent influence on child outcome

1 ES were not reported for parent influence, but were for child outcomes

0 No assessment of parent involvement

5. Statistical analysis Was significance testing, effect sizes/confidence intervals reported for PARENT effect on CHILD outcome over time?

5. Was the outcome accurately measured to minimize bias?

0 No report of parent engmnt/no fidelity

0 No report of parent engmnt/no fidelity 1 All mothers in intrv attended all sessions/no fidelity

2 % of parents engd with material amount read assessed and reported/no fidelity required 0 No report of parent engmnt/no fidelity

0 No report of parent engmnt/no fidelity

6. Engagement/ Fidelity Was engagement with PARENT intervention, or facilitator fidelity assessed and reported?

6. Have the authors identified all important confounding factors?

1 3 m posttest

1 3 m f/u w diagnostic instrument but no long-term assessment

0 No f/u

0 No f/u

1 3 m f/u

0 Baseline, posttest only/no incidence assessment

7. Follow-up Was there a follow-up assessment that showed change in child risk for ED/BD over time?

7. Was the follow-up of participants complete enough?

2 ChEAT, SIQYA

2 A range of nonvalidated, and subscales from validated measures

1 Uncontrolled RM parents-only

2 Cluster RCT, schools as cluster

2 Cluster RCT, schools as cluster

2 Cluster RCT, schools as cluster

2 Cluster RCT, Girl Scout troop as cluster

Jones (2012)44

Marcus (2009)37

McVey (2007)38

McVey (unpub)49

NeumarkSztainer (2000)39

2 SATAQ, ChEAT, etc

2 ChEAT, BMI observed

2 WCS, EDI, EDEQ 1 others

1 A range of nonvalidated measures, or items from validated measures

1 Controlled, nonrandomized RM

Haines (2006)43

2 ChEAT, BMI

2. Child measure

2 RCT w parents randomized

Continued 1. Design

FollansbeeJunger (2010)48

TABLE 1. Adaptation

0 5th and 6th grade, girls in Girl Scouts only

2 large sample, boys 1 girls, range in age 0 6th grade girls only

2 large sample, boys 1 girls, range in age

0 46 adolescent girls at risk of AN

2 Boys and girls, 4th– 6th grade children

1 Boys and girls, 8–13 years, obese/overweight children only

3. Recruitment

2 Classes in interv schools were randomly assigned to two arms: studentonly versus student 1 parent receiving interv 0 Parents provided qualitative feedback on their perceptions of their child’s engagement with the program

0 No assessment of parent involvement

0 Parents completed post-test only

2 3-arm RCT design compared parent 1 child, parentonly, and waitlist cont conditions 1 Interv versus cont compared, but no way of assessing whether effects were due to child or parent participation in interv modules 1 Child AN-risk measured according to parent adherence w interv

4. Assessment of parent effect

0 No assessment of parent involvement

0 Due to low parental involvement (n 5 28), analyses restricted to student-only versus cont

0 Authors report children in interv did better bc parents involved, but engmnt not assessed 0 No assessment of parent involvement

0 Decrease in AN-risk for 16 of 19 daughters whose parents in interv. But no sig bc small n

0 No direct assessment of parental involvement

2 RM ANOVAs assess group 3 time interaction, partial g2 reported

5. Statistical analysis

1 No report of parent engmnt/fidelity was monitored

0 Workshop attendance reported/no fidelity

0 No report of parent engmnt/no fidelity

0 No report of parent engmnt/no fidelity

2 Parent engmnt with online modules assessed/no fidelity required

0 No report of parent engmnt w materials (did report % attending family night)/no fidelity

0 No report of parent engmnt/no fidelity

6. Engagement/ Fidelity

1 3 m f/u but no incidence assessment

1 12 m f/u but no incidence assessment

1 6 m f/u

0 ED measure at posttest only

0 AN-risk assessed at posttest only

1 Pre and 8 m posttest but no incidence reporting

2 % meeting ChEAT clinical cut-off at 6 m f/ u

7. Follow-up

2 ChEAT 1 others

2 EAT-26, BMI

2 ChEAT, MAEDs, BIA, BMI

2 Cluster RCT, schools as cluster

1 Controlled, nonrandomized RM

2 RCT, parents randomized

2 RCT, parents randomized

2 RCT, family randomized

1 Wait-list controlled, non-randomized RM

RussellMayhew (2004)50

Smolak (1998)42

Sniezek (2006)51

Trost (2006)52

Van Ryzin (2013)45

VarnadoSullivan (2001)53

2 Boys and girls, 6th and 7th grade

1 Boys and girls, 6th grade only

1 Girls only aged 10–15 years

1 Only inc 5th grade, large sample, boys and girls 1 Girls aged 14–16 years only

2 Large sample, boys 1 girls, range in age 2 Boys and girls, aged 8–14 years

3. Recruitment

2 Multiple regression conducted to assess whether changes in parent scores predicted changes in daughter’s ED and BD risk 2 Only parents received interv and compared with cont group 1 Interv versus cont compared, interv modules provided to whole family, no ability to separate parent effect 2 Study design included two stages; (1) students only, (2) parents 1 students, with measures at each point.

2 Schools randomized to Student-only, student 1 parent, student 1 parent 1 teachers, parent 1 teachers only, or waitlist cont 0 No assessment of parent involvement

0 No assessment of parent involvement

4. Assessment of parent effect

0 Parent uptake of (2) was poor, no stat analyses conducted

2 RM ANOVAs used to assess group 3 time interactions, partial g2 reported 1 SEM to assess hypothesized model

2 Sig testing and ES reported

0 No assessment of parent involvement

1 RM ANOVAs assess group 3 time interactions. No ES or CIs reported

0 No assessment of parent involvement

5. Statistical analysis

2 Engmnt reported/ Fidelity measures were planned

1 Parent engmnt reported/no fidelity

2 Parental engmnt reported/fidelity monitored

2 Report intv versus cont parent engmnt w materials/no fidelity required

0 No report of parent engmnt /fidelity

1 Report on engmnt w workshops/no fidelity

0 No report of parent engmnt/no fidelity

6. Engagement/ Fidelity

1 10 week f/u but no incidence assessment

1 10-year f/u overweight (BMI) but not ED or BD

1 3 m f/u but no incidence assessment

0 Pre, post only

0 Pre, post only

0 Quant measures at pre, post only, focus group at 3 m f/u

1 6 m f/u

7. Follow-up

AN, Anorexia Nervosa; BD, Body dissatisfaction; Cont, Control group; Engmnt, Parental Engagement with intervention materials; Engd, Engaged with materials; ES, Effect size; f/u, Follow-up measure; Interv, Intervention; ED, Eating disorder; SEM, Structural equation modeling.

2 BDS, DRES, DIS, EDDS

2 EDI, EDE-Q, WCS

2 Body Esteem Scale, qs about health eat

2 EDI, phys appearance ratings

2. Child measure

2 Cluster RCT, class as cluster

Continued 1. Design

O’Dea (2000)40

TABLE 1. Adaptation

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found to be at risk through screening, only one parent–child dyad attended the intervention program. Quantitative evaluation of the program could therefore not be conducted, although the authors and other commentators concluded that their study importantly demonstrated a lack of motivation among parents of at-risk adolescents to identify and respond to their child’s problem eating.27,53,54 Two studies scored one point on CASP item 5, indicating they were able to provide some highly relevant data but with ambiguous validity.46,50 Bruning Brown46 adapted the Student Bodies online program55 for adolescents and their parents. Parents were provided with an unstructured web-based program to be completed any time over a four-week period. Content included a bulletin-board forum, acceptance of weight and shape diversity, discouraging negative parental attitudes and behaviors affecting daughters such as teasing or pressure to diet, and exercises to develop positive communication strategies. Parents were randomized to either control or intervention arms, although their daughters were also independently randomized to either control or intervention arms, which meant that in one dyad both control and intervention participants were possible. Significant differences were found between the adolescent intervention and adolescent control groups on eating pathology measures, and between the parent intervention and parent control groups on measures of criticism, suggesting the intervention was effective in some domains. Nevertheless, qualitative evaluation of the parent component revealed that only 11 of the 22 intervention group parents actually logged-on to the program, and of those, only eight reported having read 80% or more of the content. There was, therefore, very low uptake among parents and it is perhaps not surprising that no differences were found between adolescents’ whose parents received the intervention and adolescents’ whose parents were in the wait-list control group. In the Russell-Mayhew study,50,56,57 there were four arms including: students-only, students 1 parents, students 1 teachers, and students 1 parents 1 teachers. Parents and teachers did not complete measures, but attended workshops. The student intervention included a play discussing body image and eating issues. Students were stratified into elementary school and junior high groups and received age-appropriate modifications of the program. In the elementary school students, compared with the group without parent involvement, the two groups involving parents showed greater improvements on the Piers Harris Children’s SelfConcept Scale, which measures dimensions such 164

as satisfaction with physical appearance and personal attributes, behavior and anxiety. Because this study did not report on effect sizes and confidence intervals, which are required to assess for error in statistical significant testing, it scored one point on CASP item 5, rather than two. Despite this, the study had a large sample and reported positive outcomes for children whose parents were involved in the prevention intervention. Indeed, this study is particularly notable in that it included an almost equal proportion of boys and girls, and children as young as eight years, but still managed to find an effect for parental involvement.

High-Quality Data on Parental Involvement

Studies that scored two points on both CASP item 4 and CASP item 5 provided the most specific, valid and reliable data for understanding how parents can be effectively involved in prevention programs. Of the four studies that achieved this47,48,51,52 one found that providing parents of overweight children with a prevention intervention resulted in significant child weight loss but had no effect on a direct measure of eating disorder risk,48 two found that providing parents with a prevention intervention significantly reduced their child’s body dissatisfaction and disordered eating over time,47,51 while the last found no effect of parental involvement.52 Follansbee-Junger, Janicke, and Sallinen48 randomized 68 parents with overweight children aged 8–13 years to receive a behavioral weight-loss intervention in either a parent 1 child, parent-only, or wait-list control condition. Intervention groups were provided with 12 group-sessions of behavioral family-based weight management intervention. Although both parents and children received the intervention in the parent 1 child condition, sessions were run separately. There were no significant differences found on ChEAT scores at any assessment point, between the parent 1 child and parentonly groups, so these were collapsed and compared with controls. Again, no significant differences were found across groups. However, relative to baseline, at 6-month follow-up children in the intervention groups showed significantly more weight-loss compared with the waitlist control group, suggesting that parent involvement in the intervention was effective in reducing child weight. Furthermore, the authors concluded that although their sample was overweight at baseline, children’s scores on the ChEAT were in the normal range and reports of disordered eating behaviors were very low. It was therefore likely that a ceiling effect masked any possible improvement in disordered eating. International Journal of Eating Disorders 48:2 157–169 2015

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Corning, Gondoli, Bucchianeri, and Salafia47 randomly allocated 31 mothers and their 12–14 year old daughters, as dyads, to either a control or intervention condition. The intervention involved four, weekly, 90-min workshops provided to mothers only. At both posttest and 3 month follow-up, girls whose mothers were in the intervention group perceived less pressure to be thin from their mothers, and showed lower drive for thinness in themselves. Although three of the four high quality studies investigated perceived parental pressure for thinness, this study was the only one to report a significant group by time interaction. Sniezek51 used a hardcopy version of the Student Bodies materials from the earlier Bruning Brown study,46 but tried to enhance the parent component by transforming web-based content into hardcopy parent handouts. Both parents and adolescents completed measures of appearance-based criticism, and adolescents also completed the EDI-2, EDE-Q, and Weight Concerns Scale. Although parents in both groups reported being less critical over time, no significant differences on childperceived parental criticism were found between adolescents whose parent received the intervention and adolescents whose parent received the control materials, which suggests that the intervention had no effect. Interestingly though, an analysis based on only those daughters who had perceived a reduction in parental criticism after the intervention, found that their change score reliably predicted a change in the daughter’s weight concerns. So daughters who perceived a reduction in criticism from their parents felt less concerned about their weight over time. In the Trost study,52 parents of middle-school girls were randomized to a wait-list control or an intervention program of three, weekly, 90-min group education sessions facilitated by psychology graduates. Parents’ thin-ideal internalization, body dissatisfaction, and dieting behaviors were found to be significantly lower in the intervention group over time, suggesting the intervention had a positive impact on parents. However, no significant group by time interactions were found. Despite this, children of parents in the intervention group did show reductions in scores on thin-ideal internalization, dieting behaviors, and bulimia nervosa symptoms, which suggests that the sample may have been too underpowered to detect an effect. This study had similar findings to the Sniezek study51 in that there were no significant differences in child-perceived pressure to be thin, though parents reported applying less pressure on their children over time. Unlike the Sniezek study51 though, the author did not look at the sub-sample of International Journal of Eating Disorders 48:2 157–169 2015

children who perceived a reduction in parental pressure and how this influenced other child outcomes.

Discussion The literature on body dissatisfaction and eating disorder prevention programs involving parents was systematically reviewed to consolidate current knowledge and provide directions for future program development and evaluation research. The study quality assessment using the CASP matrix revealed that, although many studies provided large and unbiased data on intervention programs for students, many studies provided no data on how parents affected child outcomes. Studies with medium quality data (those scoring one point on CASP item 4) revealed that many prevention interventions achieve meaningful reductions in child risk factors, such as overweight and pressure to be thin. Yet, due to problems with evaluation design, underpowered parent sample sizes or choice of analytic methods, it was not clear whether these significant improvements were the result of the child receiving an effective prevention intervention, or the result of their parent being involved in the program as well. Four high quality studies provided mixed data, with two being inconclusive on the role of the parent intervention, while the others reported that parental involvement in prevention programs significantly improved child outcomes. It is important to note that, although many studies across the 20 reviewed did not find significant group by time interactions on parent measures (e.g., Ref. 52), this does not equate to evidence that parents have no role to play in prevention interventions. In most studies, parent measures were hampered by small and inadequately powered parent sample sizes, or prevention programming that was not effective in motivating parents to change complex attitudes or behaviors toward body image and eating. In the future, if studies can find significant changes in relevant parent behaviors, such as reduction of child criticism, pressure to be thin or pressure to diet, and significant effects on child outcomes are still not found, then it could be concluded that parents do not add benefit to prevention programs, above and beyond what can be achieved by providing intervention components directly to children and adolescents themselves. In contrast, the two studies that were able to sample children who perceived a significant reduction in pressure for thinness from their parents, found a corresponding positive impact on the child’s risk of body dissatisfaction and disordered eating.47,51 Taken together, these studies suggest that changing 165

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parent behavior can effectively reduce the risk of body image and eating problems in children, although this is a complex task that is difficult to achieve, according to the studies reviewed. Small parent sample sizes were almost ubiquitous in the literature and provide an enormous hurdle in understanding how parents can be effectively engaged in preventing body image and eating problems. One possible explanation for difficulty in involving parents is the use of intervention programs that were unlikely to result in parent motivation to engage or in the skills required for change. Although the studies reviewed commonly reported being influenced by a psychological model or theory in determining which established risk factors or vulnerable population would be the target of their intervention (see Supporting Information), the specific content of prevention programming was rarely built on psychological models relevant to health behavior or behavior change, such as the theory of planned behavior58 or the informationmotivation-behavioral skills model (IMB).59 For example, providing parents with brief written information outlining the child curriculum was a common approach, often supported by social–cognitive theory, which suggests that targeting all influencing factors in a child’s environment is important. However, uptake and engagement with these materials by parents was rarely assessed, or alternatively it was found to be low. In contrast, the IMB model suggests that information, motivation and behavioral skills predict health behaviors, and thus, interventions can be designed to target these different elements, and that program success will increase with the number of elements targeted.60 Consistent with this model, this review found no data demonstrating that provision of written materials for parents to supplement student curriculum was an effective intervention design, even if it was motivated by social–cognitive theory. Indeed, this finding has been replicated in other areas of the eating disorders literature.61 A stronger focus on developing program content informed by psychological models relevant to behavior change would therefore be of benefit to the prevention research field. In the Sniezek51 study, the fact that a subsample of daughters perceived a reduction in pressure to be thin, and this reduction significantly predicted a reduction in concerns about weight, suggests that the intervention was effective for some parents and that had this proportion been larger, a significant group by time interaction might have been found. Although the authors used a measure of parental engagement and found no significant differences between intervention and active control groups, an 166

analysis of engagement on the subgroup of parents whose daughters perceived a reduction in pressure for thinness, was not conducted. It is conceivable that parents who engaged more frequently or in greater depth with the program materials, showed a stronger change in their behavior, leading to a stronger perception in their daughters. Without an analysis of engagement, however, the cause of the result can only be conjecture. Another important consideration to come from the Sniezek51 and Trost52 studies is that a child’s perception of their parent’s behavior is more important than the parents’ perception of their own behavior. This highlights the need for careful design of evaluation studies and the importance of including child self-report measures, rather than reliance on parent-report only. Rodgers and Chabrol1 have highlighted the difficulties in reliably measuring complex risk factors, such as parental pressure for thinness, when conducting prevention research. However, sophisticated measures of parent–child interactions are currently available, such as video monitored real-time coding of positive and negative reactions during event-planning and conflictresolution tasks.62 Such measures provide insight into how emotional interactions between parents and their adolescents can determine risk for psychopathology, but are yet to be utilized in the eating disorders field and are very resource intensive. One concerning finding of the current review is that measuring and communicating a child’s at-risk status does not appear to improve parent engagement with prevention programs. Varnado-Sullivan et al.53 and Jones et al.44 found that parents declined participation or did not engage with program materials, despite being told of their daughter’s at-risk status. Jones et al.44 provide some insight into this problem though. They provided a 6 week online prevention program for parents of adolescents aged 11–17 years. They found that a daughter’s eating disorder risk status was positively correlated with the likelihood of parents engaging with program materials; parents of the girls who already met criteria for Anorexia Nervosa logged on more frequently and engaged with more program materials than parents of girls who were screened at high-risk. Similarly, parents of girls screened at high-risk logged on more frequently than parents of girls screened at moderate-risk. It is, therefore, possible that parents in this and the Varnado-Sullivan et al.53 studies did not believe their daughters were sick enough to warrant intervention, despite the adolescents being screened at-risk. These findings highlight the need for increased mental health literacy for eating disorders in the community. It may International Journal of Eating Disorders 48:2 157–169 2015

PARENTS AND PREVENTION

be that common misconceptions around disordered eating, such as “dieting is healthy” or “weight-loss should be encouraged in children,” are overriding the call for parents to intervene early when their child is showing signs of disordered eating. Much more work in educating parents about the early warning signs of eating disorders and the long-term damaging effects that they can lead to, is clearly needed and relevant interventions are currently available.63, 64 In addition to poor mental health literacy, another issue hampering parental engagement could be the stigmatization of eating disorders and a reluctance to enroll in a study that might suggest to the wider community that their child has an eating problem. One innovative approach to overcoming poor engagement in eating disorder research in particular, is to provide parents with general parenting programs designed to improve relationship quality. Van Ryzin and Nowicka45 used this approach and found increased relationship quality reliably predicted improvements in maladaptive eating attitudes. Although not included in this review, as it is yet to be evaluated using an experimental design, another promising intervention has been developed by Haines et al.,65 in which healthy weight-related messages are embedded in a general parenting program. Although a range of explanations have been offered in this review, research investigating barriers to parent participation in body dissatisfaction and eating disorders prevention research would prove invaluable to future intervention work with parents. Without understanding the barriers parents perceive, it is very difficult for researchers to optimize intervention and evaluation design to suit parental needs. Implications for Future Research

The call by Levine and Smolak26 for greater ecological programs with children, is being heeded. However, the focus has been on school-settings without effective parent engagement. With the exception of six studies in this review,44,45,47,48,52,53 which carefully designed programs specifically for parents, all the programs reviewed were designed for children or adolescents, with a parent component built on, in an attempt to strengthen the messages being taught to children, rather than with the goal of understanding the implications of changing parental attitudes and behaviors on their child’s body image and eating. More attention, therefore, needs to be directed toward the crucial family setting. Furthermore, given that recent research suggests children International Journal of Eating Disorders 48:2 157–169 2015

aged 5–6 years have a developed body image,66 may attribute negative characteristics such as “naughty,” “mean,” and “lazy” to large body shapes67 and can exhibit behaviors consistent with body dissatisfaction, such as body checking and negative comments about their appearance,68 there is a striking need to develop programs for parents of children in the preschool years, before the foundations for body dissatisfaction and disordered eating are laid. The reviewed studies highlight a clear and current gap in our understanding of how parents can best be motivated to participate in prevention research. Despite the need to engage parents in program design being recognized 15 years ago,21 relatively little research has been conducted to understand the needs of parents, or designed to meet them. Researchers need to develop engaging programs designed to suit the particular needs of parents, coupled with robust evaluation designs, larger parent sample sizes, and useful, sensitive measures of parent influence on child risk status. While the field of eating disorders has long recognized the benefit of involving parents in eating disorder treatment,69 it has been slow to effectively involve parents in preventative action. The eating disorders field may fall behind advances in prevention of adolescent depression and obesity, unless it is prepared to use more creative and engaging ways to involve parents in program design and importantly, evaluation.

Conclusions This review highlights the need for researchers to clearly understand the parent perspective so that creative and engaging programs can be designed to suit their needs. To be effective, future research needs to focus on developing materials specifically for parents based on theoretical models of behavior change, within larger ecological programs for students, or within the family setting for young children. Carefully designed evaluation methods with long-term follow-up are also needed. Despite these gaps, this review demonstrates that quality prevention programs for parents are being conducted, and are capable of reducing risk factors for body dissatisfaction and eating disorders in children.

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Parents and prevention: a systematic review of interventions involving parents that aim to prevent body dissatisfaction or eating disorders.

To systematically review the literature on interventions involving parents that aim to prevent body dissatisfaction or eating disorders in children, a...
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