RESEARCH ARTICLE

The Spanish Validation of the Accommodation and Enabling Scale for Eating Disorders Among Carers: A Pilot Study Yolanda Quiles Marcos1*, María José Quiles Sebastián1, Lidia Pamies Aubalat2, Ana Rosa Sepúlveda García3 & Janet Treasure4 1

Health Psychology Department, University Miguel Hernández, Elche, Alicante, Spain Educative Department, San Antonio Catholic University of Murcia, Murcia, Spain 3 Biology and Health Psychology Department, University Autónoma of Madrid, Madrid, Spain 4 Psychological Medicine Department, King’s College London, London, UK 2

Abstract Literature suggests that families may accommodate patients’ symptoms in attempts to alleviate family conflict and stress. These accommodating and enabling behaviours may have a negative impact on carers and those they care for. There are no self-report questionnaires validated in Spanish to measure accommodation among relatives of patients with an eating disorder. The aim of this study was to examine the psychometric properties of the Spanish version of the Accommodation and Enabling Scale for Eating Disorders (AESED-S) among relatives of eating disorder patients. A cross-sectional study of 90 relatives was carried out to explore the factor structure, reliability and validity of the AESED-S. The internal consistency of the Spanish version of the AESED subscales was good, ranging from .89 to .81. The correlation of the five subscales with conceptually related measures (negative caregiving experience and distress) supports the convergent validity of this instrument in this sample. Results indicated that the Spanish version of the AESED provides a reliable and valid tool for assessing family accommodation in the context of having a relative with an eating disorder. Copyright © 2015 John Wiley & Sons, Ltd and Eating Disorders Association. Keywords anorexia nervosa; bulimia nervosa; family therapy; psychometrics *Correspondence Yolanda Quiles, Health Psychology Department, University Miguel Hernández, Avda. de la Universidad s/n C.P. 03202, Elche, Alicante, Spain. Email: [email protected] Published online 29 June 2015 in Wiley Online Library (wileyonlinelibrary.com) DOI: 10.1002/erv.2378

Introduction In the last decade, there has been an increase in the scientific literature on psychological distress and negative experience of care in relatives caring for patients with an eating disorder (ED) (Dimitropoulos, Carter, Schachter, & Woodside, 2008; Sepúlveda et al., 2014; Whitney et al., 2005; Treasure, Gavan, Todd, & Schmidt, 2002; Zabala, Macdonald, & Treasure, 2009). Nevertheless, it appears that the carer’s role is important for the recovery of these patients; thus, the evaluation of the carers’ coping strategies will be relevant for the treatment in ED (Treasure et al., 2007). Literature suggests that families may accommodate patients’ symptoms in attempts to alleviate family conflict and stress (Winn et al., 2006; Whitney & Eisler, 2005; Treasure et al., 2002). Carers may tend to organize their lives around patients’ behaviours and accommodate to or enable some of the core symptoms. For example, modifying their leisure activities and work schedule because of their relatives’ needs and accepting the time and the place where food is eaten. These accommodating and enabling behaviours may produce a negative effect on carers and patients (Goddard, MacDonald, & Treasure, 2011; Kyriacou, Treasure, & Schmidt, 2008; Zabala et al., 2009). These behaviours may

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unconsciously perpetuate patients’ symptoms, as proposed by the cognitive interpersonal maintenance model of EDs (Schmidt & Treasure, 2006). Moreover, Sepúlveda, Kyriacou, and Treasure (2009) proposed that family accommodation may have a significant role in the patient’s response to the treatment. Therefore, it is relevant to have adequate tools capable of assessing carers’ level of accommodation to ED behaviours. Based on the Family Accommodation Questionnaire (Calvocoressi et al., 1995) that evaluates the extent to which relatives of patients with an obsessive–compulsive disorder engage in different types of accommodating behaviours, Sepúlveda, Kyriacou, and Treasure (2009) developed a questionnaire that measures family accommodation in ED in a British sample. The Accommodation and Enabling Scale for Eating Disorders (AESED) is made up of 33 items that are divided into five scales: Turning a blind eye, Avoidance and modifying routine, Meal ritual, Control of family and Reassurance seeking. The AESED has shown high internal reliability that ranged from .77 to .92. The AESED subscales showed significant correlations with anxiety and depression, negative caregiving and expressed emotion levels. The development and validation study of the AESED showed that it is a useful tool for evaluating ED carers’ accommodation and is also sensitive to change after

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interventions applied to improve carers’ coping skills (Sepúlveda et al., 2009). Recently, research has been published that confirms the factor structure of this questionnaire with data from 268 carers of people with anorexia nervosa and provides further validation of the AESED as a tool to assess modifiable elements of caregiving for someone with an ED (Hibbs et al., 2014). There are no self-report questionnaires validated in Spanish to measure accommodation among carers of patients with EDs. This is a preliminary study validation, and the aim was to examine the psychometric properties of the Spanish version of the AESED among carers in EDs.

Method Participants Ninety carers of outpatients with an ED participated in this study. Participants were recruited from the Eating Disorder Unit at San Juan University Hospital, in Alicante (Spain). These carers had a relative with an ED diagnosed by mental health professionals at the hospital. The average sample age was 47.8 years (SD = 8.1), 38.9% were male and 61.1% female. 57.8% were patients’ mothers, 32.2% their fathers, 3.3% their partners, 4.4% siblings and 2.2% others. 42.9% of the fathers and 48.1% of the mothers were spending more than 21 contact hours per week with the patient. The patients had been diagnosed with an ED by a standard clinical interview following criteria of the Diagnostic and Statistical Manual of Mental Disorder, fourth edition, revised (American Psychiatric Association, 2000). They were interviewed in the ED unit by a qualified psychologist after one of their treatment session. The patients were 91.7% females with a mean age of 18.8 (SD = 6.0) years. 55.7% were diagnosed with anorexia nervosa (AN) restrictive, 9.8% AN purgative, 6.6% bulimia nervosa (BN) purgative, 1.6% BN non-purgative and 13.1% with and EDs not specified. Procedure Data were collected as part of the baseline assessment of a research that evaluated a skills-based intervention for carers of someone with an ED. Carers were recruited from the Eating Disorder Unit at the previously named Hospital. Their participation was voluntary, and carers did not receive incentives for their participation. Carers were informed about the research, and they signed the consent form. This study was approved by the Hospital Ethics Committee (R-12/312). To be eligible for this study, the carers had to be currently living with a person with an ED. Adaptation and cultural validation The guideline for instrument adaptation across countries proposed by Guillemin, Bombardier, and Beaton (1993) was used. This guide proposes different steps: (1) Two expert bilingual translators, with knowledge of the research’s framework, carried out two independent translations of the original version, from English into Spanish. (2) Comparison of the translations to assess differences in interpretation and to identify points of disagreement between them, reaching an agreement for the first version. This version was translated back to English by two other translators. (3) Researches reviewed this version and checked that it was accurate to assess the construct of accommodation. (4) In order to

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evaluate the understanding of the items and the response scale, a pilot sample of 11 carers was used, identifying terms subject to confusion and possible difficulties in the scale’s application. (5) Finally, pertinent adjustments in the writing were made, considering the existing terminology in the Spanish literature on EDs and drafting the definitive version presented in this paper. The translation has been approved by the questionnaire authors. Measures Clinical and demographic questions Carers completed a demographic questionnaire that included details about the carer (including age, gender, marital status, employment status and education level); information about the patients’ diagnosis, age, gender, onset and duration of the illness; and aspects of caregiving experience (e.g. average of daily hours of face-to-face contact). Accommodation and Enabling Scale for Eating Disorders (Sepúlveda, Kyriacou & Treasure, 2009) The AESED was designed to measure accommodation and enabling behaviours by families of people with EDs. The instrument has 33 items and five factors: Avoidance and modifying routine, Reassurance seeking, Meal context ritual, Control of family and Turning a blind eye. Its items were evaluated on a 5-point Likert scale (where 0 = never, 1 = rarely, 2 = sometimes, 3 = often and 4 = nearly always). The overall AESED score is obtained by summing up the unweighted scores of all the items: the total scale is scored from 0 to 132. A high score is associated with high family accommodation to ED symptoms. The AESED has shown high internal reliability in terms of Cronbach’s alpha that ranged from .77 to .92. The Hospital Anxiety and Depression Scale (HADS) (Zigmond & Snaith, 1983; Snaith, 2003) The HADS is a 14-item instrument designed to detect the presence and severity of anxiety and depression. The scoring of both subscales ranges from 0 to 21. High scores indicate a greater level of anxiety and depression. The subscales have shown high internal consistency (.80 to .93 for anxiety and .81 to .90 for depression). This questionnaire has been translated into a Spanish version and validated in a clinical sample (López-Roig, Terol, Pastor, Massutí, & Rodríguez-Marín, 2000; Quintana et al., 2003) and validated in general population sample with similar reliability (Terol et al., 2007). The Cronbach alpha coefficient was .86 for each subscale. In our study, the Cronbach alpha value for Anxiety subscale was .88 and for Depression subscale .84. General Health Questionnaire (GHQ-12) (Goldberg & Williams, 1988) The GHQ-12 was used to measure carers’ level of psychological distress. Each item is rated on a 4-point scale with scores ranging from 0 to 36, with higher scores indicating increased psychological distress. The Cronbach alpha was .91. The Spanish version has been validated with a satisfactory internal consistency (Cronbach alpha of .76) (Lobo & Muñoz, 1996; Rocha, Pérez, RodríguezSanz, Borrell, & Obiols, 2011). In our study, the Cronbach alpha value was .85.

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The Experience of Caregiving Inventory (ECI) (Szmukler et al., 1996) The ECI is a measure of stress, appraisal and coping in carers of an individual with a severe mental illness. The ECI is a 66-item self-report questionnaire (using a Likert scale method scored from 0 to 4) grouped into eight negative subscales (Difficult behaviours, Negative symptoms, Stigma, Problems with services, Effects on family, Need to backup, Dependency and Loss) and two positive subscales (Positive Personal Experiences and Good Relation with the Patient). The eight negative subscales measure negative aspects of caregiving and have reliability ranging between .74 and .91. A higher score indicates more negative appraisals (ECI-negative; ranges from 0 to 208). Positive scales measure positive aspects of caregiving. Higher scores indicate positive appraisals (ECI-positive; range from 0 to 56). The Spanish version obtained a satisfactory internal consistency of .84 for the positive dimension and .93 for the negative dimension (Sepúlveda et al., in press). For this work, as in the original, we have only used the eight negative subscales. In our study, the Cronbach value ranged from .66 to .87. The Family Questionnaire (FQ) (Wiedemann, Raiky, Feinstein, & Hahlweg, 2002) The FQ consists of 20 items measuring expressed emotion, 10 for criticism (CC) and 10 for emotional over-involvement (EOI). Scoring ranges from 1 as ‘never/rarely’ to 4 as ‘very often’, and a higher total score indicates higher expressed emotion. The FQ has good internal consistency (ranging from .78 to .80 for EOI and from .91 to .92 for CC). The original authors provide a cut-off point of 23 for CC as an indication of high criticism and 27 for high EOI. The Spanish version obtained a satisfactory internal consistency of .83 for the CC subscale and .72 for the EOI subscale (Sepúlveda et al., 2014). In our study, the Cronbach alpha value for CC subscale was .86 and for EOI subscale .81. Statistical analysis Data were analysed using IBM SPSS Statistics 22.0. To explore the structure of the AESED (Armonk, NY: IBM Corp), a principal components extraction method with varimax rotation was employed, using a forced five-factor model, following the same procedure as the original authors. However, an oblique rotation was also carried out with results showing that the internal structure remained basically unchanged compared to varimax rotation. The Kaiser–Meyer– Oklin (KMO) measure of sampling adequacy and Barlett’s test of sphericity are reported for assessing factorability of the data. We also used descriptive statistics such as means and standard deviations for each item, to explore their distribution in the Spanish sample. With regard to the reliability analyses, internal consistency was established using Cronbach’s alpha coefficient for the total scale and items scale. Item–total subscale Pearson correlations were also calculated. Convergent and discriminant validity was established by correlating the AESED-S with the five factors scores and ECI-negative dimension, HADS-Depression and HADS-Anxiety, FQ-CC and FQ-EOI, and GHQ-12 total score, using Pearson correlation. Tucker’s congruence coefficient (Tucker, 1951) as a meaningful index of factor similarity was calculated, between the factors of the original version of the AESED and the factors obtained by our research; a value between .85 and .94 indicates an acceptable 64

factor congruence, while values greater than .94 indicate good factorial congruence. A congruence below .85 will be interpreted as indicative of any factor similarity at all (Lorenzo-Seva & ten Berge, 2006).

Results Internal structure Factor analysis of the AESED item scores in 90 caregivers of patients with an ED yielded five factors with eigenvalues greater than one, accounting for 63.93% of the cumulative variance. Both Bartlett’s test of sphericity [χ 2(528) = 1760,712, p < .001] and the KMO index (0.739) confirmed the suitability of the correlation matrix for carrying out this analysis. The first component gave an eigenvalue of 9.93 and explained 30.10% of the total variance, which includes the main item loadings that correspond to the factor Meal ritual in the original version. All of the items from this factor correspond to the original version except item 17 ‘Accommodation of the exercise routine of the relative with ED’, which in the original version corresponds to the factor Reassurance seeking (with a loading of 0.40). As the content of the item does not match the factor label (Meal ritual), it was not included in this factor. Item 17 was included in the Reassurance seeking factor. The second factor presented an eigenvalue of 4.20, explaining 12.72% of the total variance, and included the items that evaluated Control of family. Two items (24 and 31), which come under the factor ‘Avoidance and modifying routine’ in the original version, saturated this factor. In this study, item 24 ‘On the whole, to what extent would you say that the relative with an ED controls family life and activities?’ is maintained in the ‘Control of family’ factor as we consider that this item is more coherent with the content of this factor, because it refers to the control a person with an ED establishes over the family. However, item 31 ‘Has helping your relative in the previously mentioned ways caused you distress?’ that had a factorial loading of 0.518 was excluded because its content does not match the factor label, and it was included in the original factor ‘Avoidance and modifying routines’. The third factor obtained an eigenvalue of 2.74 explaining 8.30% of the total variance. The principal item loadings in this factor corresponded to the subscale Reassurance seeking. The seven items coincide with the original version, except item 10 ‘Your relative with an ED involves a family member in repeated conversations about self-harm’, which did not present a factorial loading greater than 0.4 in any factor. The descriptive analysis of the item response showed that the average score was 0.41. This score could be due to the fact that, as indicated in the sample description, 55.5% of the patients were diagnosed with restrictive anorexia nervosa, whose characteristic symptoms do not include ‘selfharm’. However, although its factorial loading is not adequate, as ‘self-harm’ is considered a symptom that is characteristic of other ED diagnoses, like BN or purgative AN, we decided to maintain this item in the factor. Also, it is important to continue counting on the information that this item can provide us with when the questionnaire is administered to ED relatives among whom there is a high representation of purgative diagnoses. Item 10 is included in this factor because its content matches the factor label. The fourth factor presented an eigenvalue of 2.42 and explained 7.34% of the variance. It included the items corresponding to

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the subscale Turn a blind eye, which all coincided with the original version except for 33. Item 33 ‘Has your relative become angry or abusive when you have not provided assistance?’ corresponded to the factor ‘Avoidance and modifying routine’ in the original version. Since the content is not coherent with the factor Turn a blind eye, the item was included in the corresponding factor from the original version. The last component gave an eigenvalue of 1.80 and explained 5.44% of the total variance, and the item loadings were principally those that evaluated Avoidance and modifying routine. Seven items that coincide with those from the original version saturated this factor, and items 33 and 31 were added as previously indicated (Table 1).

items. The internal consistency index was also calculated using Cronbach’s alpha for each of the subscales. Table 2 shows the psychometric properties for each of the items within each factor. As seen in Table 2, internal consistency for the four subscales was high, ranging from .79 to .89, and all the items presented a test–item correlation higher than .40, except item 10 (.39).

Item response analysis and reliability estimation Secondly, means, standard deviation (SD) and item–total correlation were calculated for the statistical analysis of the

External evidence of validity This section presents the evidence concerning the relationships between the measurements provided by correlating the scores

AESED-S subscale correlations All AESED-S subscales intercorrelated with each other, with significant and positive correlations ranging between .38 and .60, except for the ‘Turning a blind eye’ subscale. Results are shown in Table 3.

Table 1 Principal component factor analysis with varimax rotation for a 5-factor solution

Item 15. Accommodating to how the kitchen is cleaned? 12. Accommodating to how the crockery is cleaned? 11. Accommodating to what crockery is used? 14. Accommodating to what place food is eaten in? 16. Accommodating to how food is stored? 13. Accommodating to what time food is eaten? 19. Accommodating to how the house is cleaned and tidied? 17. Accommodation of the exercise routine of the relative with an eating disorder? 4. Control what other family members eat 3. Control cooking practice and ingredients used 2. Control what family members do and for how long in the kitchen 1. Control choice of food that you buy 24. To what extent would you say that the relative with and ED control …? 31. Has helping your relative in the previously mentioned ways caused …? 5. Repeated questioning about whether she will get fat? 7. Repeated seeking of reassurance about whether she looks fat in certain …? 6. Repeated questioning whether it is safe or acceptable to eat certain foods? 18. Accommodation of routines of checking their body shape or weight? 9. Repeated conversations about negative thoughts and feelings? 8. Repeated conversations about ingredients and amounts in food prepare 22. Ignore kitchen left in a mess 21. Ignore if money is taken 20. Ignore food disappearing 23. Ignore bathroom left in a mess 33. Has your relative become angry/abusive when you have not provided …? 10. Repeated conversations about self-harm? 30. Have you modified your leisure activities because of your relative’s …? 26. How often did you assist your relative in avoiding things that might …? 28. Have you modified your family routine because of your family …? 27. Have you avoided doing things, going places or being with people …? 29. Have you modified your work schedule because of your relative …? 25. How often did you participate in behaviours related to your …? 32. Has your relative become distressed when you have not provided …? Variance explained for the rotated factors

Meal ritual

Control of family

Reassurance seeking

Turning a blind eye

Avoidance and modifying routines

.910 .823 .800 .785 .774 .662 .653 .603 .170 .138 .315 .091 .131 .100 .111 .031 .037 .293 .123 .068 .130 .022 .255 .060 .095 .018 .143 .056 .146 .021 .097 .345 .085 15.66%

.033 .084 .163 .226 .102 .189 .044 .174 .796 .789 .735 .712 .654 .518 .092 .136 .317 .102 .259 .498 .158 .004 .004 .147 .431 .114 .239 .058 .397 .404 .204 .057 .244 13.17%

.057 .009 .001 .054 .006 .004 .401 .399a .143 .236 .289 .040 .028 .265 .840 .836 .743 .637 .572 .545 .195 .211 .069 .110 .053 .282a .091 .181 .163 .196 .208 .155 .238 11.99%

.104 .106 .189 .027 .380 .222 .022 .075 .051 .210 .004 .231 .093 .059 .192 .082 .188 .045 .209 .199 .871 .831 .769 .674 .508 .376 .285 .230 .058 .324 .160 .012 .373 11.62%

.070 .006 .004 .202 .098 .229 .166 .156 .044 .072 .091 .191 .265a .247a .084 .015 .033 .255 .424 .236 .078 .034 .034 .345 .325a .363 .760 .664 .659 .648 .646 .560 .411 11.48%

a

Expected factor according to Sepúlveda et al. (2009).

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Table 2 Descriptive results of the items and item–test correlation Item

15 12 11 14 16 13 19 4 3 2 1 24 5 7 6 18 9 8 17 10 22 21 20 23 33 31 30 26 28 27 29 25 32

αa

RIT Meal ritual 0.41 1.03 0.40 0.96 0.42 0.94 0.80 1.26 0.55 1.11 1.18 1.33 0.48 0.95 Control of family 1.73 1.41 2.08 1.38 1.40 1.17 2.02 1.25 5.14 2.71 Reassurance seeking 1.08 1.25 1.25 1.26 1.42 1.36 0.91 1.20 1.62 1.37 1.92 1.40 0.74 1.12 0.41 0.44 Turning a blind eye 0.51 0.83 0.28 0.76 0.55 1.04 0.83 1.19 Avoidance and modifying routines 1.55 1.12 0.88 1.10 1.51 1.40 1.89 1.44 1.50 1.33 1.46 1.40 1.04 1.35 1.30 1.52 1.28 1.15

α = .89 .85 .86 .87 .87 .87 .89 .88 α = .79 .75 .71 .75 .75 .83 α = .85 .81 .82 .82 .83 .82 .82 .84 .84 α = .83 .72 .78 .84 .82 α = .85 .84 .84 .82 .83 .82 .81 .85 .85 .83

.83 .75 .73 .73 .71 .56 .58 .61 .73 .64 .63 .57 .78 .69 .72 .55 .67 .63 .40 .39 .82 .74 .57 .62 .50 .46 .71 .58 .70 .76 .41 .44 .55

a

Reliability without the item.

Table 3 AESED-S subscale correlations Avoidance and Reassure Meal Control of Turning a modifying routines seeking ritual family blind eye Avoidance and modifying routines Reassure seeking Meal ritual Control of family Turning a blind eye

1 .46** .41** .55** .40**

1 .35** .60** .18

1 .45** .38**

1 .18

Congruence coefficient Tucker’s congruence coefficient as a meaningful index of factor similarity was calculated. Table 5 shows the results. While factor Avoidance and modifying routines reached an index equal to .94, considered as an acceptable congruence, the other factors obtained values greater than .94, indicating good factorial congruence. Tucker’s congruence index between non-analogous factors was below .85.

Discussion This preliminary study has verified that the AESED-S is a valid and reliable instrument to measure caregivers’ behaviours that Table 4 Correlations (Pearson) between the AESED subscale scores and ECInegative subscales, HADS, GHQ-12 and FQ Avoidance and Reassure Meal Control of Turning modifying routines seeking ritual family blind eye ECI Difficult behaviour Negative symptom Stigma Problem services Effects on family Need to back up Dependency Loss HADS-Depression HADS-Anxiety GHQ-12 FQ-CC FQ-EOI

.57** .55** .52** .41** .42** .27* .54** .48** .46** .47** .37** .43** .52**

.57** .39** .51** .39** .44** .31** .48** .49** .35** .38** .36** .32** .49**

.46** .32** .33** .24* .17 .28* .27* .19 .27* .20 .19 .47** .22*

.62** .52** .33** .43** .29* .17 .42** .43** .36** .35** .40** .54** .47**

.36** .42** .26* .24* .33** .32** .29** .30** .18 .18 .12 .37** .11

1

Note: AESED-S, Spanish version of the Accommodation and Enabling Scale for Eating Disorders. *p ≤ .05; **p ≤ .01; ***p ≤ .001.

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from the five AESED-S subscales with the level of negative appraisals measured by the eight negative subscales from the ECI, the level of depression and anxiety measured by the HADS, the level of psychological distress measured by the GHQ-12, and the level of expressed emotion measured by the FQ. The results showed coherent relationship patterns with the theory. The results are presented in Table 4. There were positive and significant associations between negative appraisals of caregiving (ECI) and the AESED-S subscale scores, except for the ‘Meal ritual’ subscale and the ‘Effects on family’ and ‘Loss’ subscales, and between ‘Control of family’ and ‘Need to back up’, which were not significant. Significant and positive correlations were found between AESED-S subscales and depression, anxiety, psychological distress, criticism and EOI, except for the ‘Turning a blind eye’ subscale, which did not show a significant correlation with depression, anxiety, psychological distress and FQ-EOI. Moreover, the ‘Meal ritual’ subscale did not show correlations with the HADS-Anxiety subscale or the GHQ-12.

Note: AESED, Accommodation and Enabling Scale for Eating Disorders; ECI, Experience of Caregiving Inventory; HADS, Hospital Anxiety and Depression Scale; GHQ-12, General Health Questionnaire; FQ, Family Questionnaire; EOI, emotional over-involvement. *Correlation is significant a the .05 level (2-tailed). **Correlation is significant a the .01 level (2-tailed).

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Table 5 Tucker congruence index Analogous factors Avoidance and modifying routines Reassure seeking Meal ritual Control of family Turning a blind eye

.94 .98 .99 .97 .99

Non-analogous factors Avoidance/reassure seeking Avoidance/meal ritual Avoidance/control of family Avoidance/turning a blind eye Reassure seeking/meal ritual Reassure seeking/control of family Reassure seeking/turning a blind eye Meal ritual/control of family Meal ritual/turning a blind eye Control of family/turning a blind eye

.65 .69 .75 .64 .17 .82 .23 .70 .45 .63

inadvertently serve to reinforce or fail to discourage symptoms or behaviours in ED. As far as we know, it is the first self-report measure validated in Spanish that makes it possible to assess family accommodation in the context of having a relative with an ED. The analyses of the psychometric properties allow us to propose a final set of 33 items grouped into five subscales: Avoidance and modifying routine, Reassurance seeking, Meal ritual, Control of family and Turning a blind eye, which as a whole match the original version of the questionnaire. The congruence coefficients have shown how the five factors show good factor congruence and illustrate the replicability of the two factorial structures. These five factors together explained 63.93% of the variance. Only item 10 ‘Your relative with an ED involves a family member in repeated conversations about self-harm’ presented a factorial loading below 0.4. Nevertheless, as this is the first validation made of this questionnaire in a Spanish population, and taking into account that ‘self-harm’ is a symptom characteristic of some of the ED diagnoses, like BN and purgative AN, we have decided to maintain this item in the questionnaire. It is important to continue to count on the information this item can provide us with when the questionnaire is administered to relatives of people with ED among whom there is a high representation of purgative diagnoses. On the other hand, the five subscales showed adequate internal consistency that was estimated with the Cronbach’s alpha coefficient. As in the original version of this questionnaire, the Avoidance and/or modified their routines to accommodate to the patient’s symptomatology subscale had the highest associations with the rest of subscales and the Turning a blind eye subscale showed the lowest associations. As the authors of the original questionnaire explain, the Turning a blind eye subscale encapsulated four items that are more characteristic of bulimia, and as our carer sample was composed primarily of AN families, this might explain why this subscale showed a low association with other subscales (Sepúlveda, Todd, et al., 2009).

The analysis of the relationships with other variables showed evidence of convergent validity in the correlations of the AESED-S subscales and the selected variables, which was just as we expected as in line with previous research (Goddard et al., 2011; Hibbs et al., 2014; Sepúlveda, Todd, et al., 2009). We found positive and significant correlations between scores on the AESED-S subscales and the ECI-negative dimensions, as well as HADS-Anxiety and HADS-Depression subscales. Furthermore, AESED-S subscales showed positive associations with the expressed emotion questionnaire, which was also just as we expected and in line with previous research. These results suggest that accommodation evaluated with a self-report instrument and from a relative’s perspective is a relevant construct that may have prognostic significance in family-based interventions, as shown in previous studies (Goddard, MacDonald and Treasure, 2011; Sepúlveda, Kyriacou, and Treasure (2009)). This instrument is sensitive to change after interventions aimed at changing intrafamily maintenance factors in ED. In conclusion, although further research with different and larger samples is still required to analyse the full extent of the psychometric guarantees of this test, we have a prospective instrument that will fill an important gap in the field of ED in Spain. This instrument provides research professionals from different health promotion fields with a tool to acquire reliable and valid measurements of accommodation in ED carers. From a clinical perspective, this study provides a validated tool to assess caregiving and the specific difficulties faced by ED carers in the Spanish context. This is important for caregiving interventions that target relevant behaviours. It is, therefore, a measure that can be of use in clinical and research contexts and can aid the identification of families that may benefit from interventions targeted at improving family responses and coping strategies. There are several limitations that should be noted. The main limitation of this paper is the low sample used to conduct a principal component analysis of a questionnaire comprising 33 items. Further research is needed with the Spanish version in larger samples. Test–retest reliability has not been assessed in this study. The predictive validity of this instrument should be assessed in future research. It would be interesting to analyse the potential impact on sensitivity to change after a family intervention. Regarding the representativeness of the sample, there was a high proportion of female carers, and the most frequent diagnosis of the patients was anorexia. Authors of the original questionnaire suggest that family accommodation could change over time; therefore, it is necessary to carry out longitudinal explorations to identify patient and family factors that may affect changes in accommodation (Sepúlveda, Kyriacou, and Treasure (2009)). Finally, it would be interesting to carry out a confirmatory factor analysis to confirm the dimensions of the AESED in the Spanish sample.

Acknowledgements Dr Sepúlveda has a postdoctoral Ramon and Cajal scholarship from the Spanish Ministry of Science and Innovation (RYC2009-05092) as well as a project funding from the same Ministry (PSI2011-23127). We express our gratitude to all the caregivers who participated in this study [San Juan University Hospital (Alicante)].

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Eur. Eat. Disorders Rev. 24 (2016) 62–68 © 2015 John Wiley & Sons, Ltd and Eating Disorders Association.

The Spanish Validation of the Accommodation and Enabling Scale for Eating Disorders Among Carers: A Pilot Study.

Literature suggests that families may accommodate patients' symptoms in attempts to alleviate family conflict and stress. These accommodating and enab...
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