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1 FAMILY DISTRESS, BODY IMA GE AND EATING CONCERNS AMONG MALE AND FEMALE COLLEGE STUDENTS BY YANEL DE MIRANDA A THESIS PRESENTED TO THE GRADUATE SCHOOL OF THE UNIVERSITY OF FLORIDA IN PARTIAL FULFILLMENT OF THE REQUIREMENTS FOR THE DEGREE OF MASTER OF ARTS IN EDUCATION UNIVERSITY OF FLORIDA 2013
2 2013 Yanel De Miranda
3 To my family, supervisors, mentors, professors, the students in the Counselor Education program, and all who have influenced my education
4 ACKNOWLEDGMENTS I thank my committee members: Dr. Sondra Smith Adcock, Dr. Edil Torres Rivera, and Dr. Roberta Seldman for their continued help and support throughout the study. I thank Dr. C ir ec ie W est Olatunji, Dr. Sherry Benton, Dr. Gizem Toska, Ronald Scott, Nadine Isaac, and Jeff Wolfgang for their help and encouragement with the study. I thank my parents for always supporting me in my education. I thank my classmates and friends for their encouragement. I thank Santiago C asanova III for always believing in me. Thank you to everyone that encouraged me through out this process.
5 TABLE OF CONTENTS Page ACKNOWLEDGMENTS ................................ ................................ ................................ .. 4 LIST OF TABLES ................................ ................................ ................................ ............ 7 LIST OF FIGURES ................................ ................................ ................................ .......... 8 ABSTRACT ................................ ................................ ................................ ..................... 9 CHAPTER 1 INTRODUCTION ................................ ................................ ................................ .... 11 Overview ................................ ................................ ................................ ................. 11 Literature Review ................................ ................................ ................................ .... 12 Body Image Dissatisfaction ................................ ................................ .............. 13 De velopment of Body Image Dissatisfaction and Eating Attitudes ................... 14 Gender Differences ................................ ................................ .......................... 17 Family Influence ................................ ................................ ............................... 22 Summary of R elevant Literature ................................ ................................ ............. 31 Aim of Study and Research Questions ................................ ................................ ... 31 2 METHOD ................................ ................................ ................................ ................ 33 Sample ................................ ................................ ................................ .................... 33 Procedures ................................ ................................ ................................ ............. 33 Measures ................................ ................................ ................................ ................ 34 Data Analysis ................................ ................................ ................................ .......... 35 Research Hypotheses ................................ ................................ ............................. 36 3 RESULTS ................................ ................................ ................................ ............... 37 4 DISCUSSION ................................ ................................ ................................ ......... 40 Comparison with Other Research ................................ ................................ ........... 40 Limitations ................................ ................................ ................................ ............... 42 Conclusion and Suggestions for Future Research ................................ .................. 43 APPENDIX A CCAPS 62 SAMPLE PROFILE REPORT ................................ ............................... 46 B CCAPS 62 SAMPLE TEST ................................ ................................ ..................... 47 C INFORMED CONSENT ................................ ................................ .......................... 49
6 D IRB 02 APPROVAL LETTER ................................ ................................ .................. 51 LIST OF REFERENCES ................................ ................................ ............................... 52 BIOGRAPHICAL SKETCH ................................ ................................ ............................ 56
7 LIST OF TABLES Table page 3 1 One way ANOVA summary table ................................ ................................ ....... 38 3 2 Univariate ANOVA sum mary table ................................ ................................ ..... 39
8 LIST OF FIGURES Figure page 2 1 CCAPS 62 Eating Concerns and Family Distress items ................................ ..... 35
9 Abstract of Thesis Presented to the Graduate School of the University of Florida in Partial Fulfillment of the Requirements for the Degree of Master of Arts in Education FAMILY DISTRESS BODY IM A GE AND EATING CONCERNS AMONG MALE AND FEMALE COLLEGE STUDENTS By Yanel De Miranda May 2013 Chair: Sondra Smith Adcock Major: Mental Health Counseling OBJECTIVE: An overall increase in e ating d isorders among youth in the United States ha s led to concern among parents and clinicians alike. Similarly, the increase in body i mage d issatisfaction has been a major concern, especially among females as studies have shown that it can lead to disordered eating and e ating d isorders. Parents may help adolescents develop a positive body image, but they may also increase body image dissatisfaction What a ssociation if any, does family distress have to body image and eating concerns among male and female college st udents ? The purpose of this research study is to examine the relationship between e ating c oncerns and f amily d istress in college students and assess whether there are any gender differences in regards to this relationship. RESEARCH DESIGN AND METHODS: Arch ival data was used from the University of Florida Counseli ng and Wellness Center based on de identified client data which was comprised of 9,903 students at the University of F lorida (6359 female, 3421 male, and 16 transgender) who accessed the Counseling completed the Counseling Center Assessment of Psychological Symptoms (CCAPS
10 62). The two subscales: Eating Concerns and Family Distress from the CCAPS 62 were used A Pearson product correlation analysis was conducted to determine whether there is a correlation between e ating c oncerns and f amily d istress. A n Analysis of Variance (ANOVA) was conducted to determine whether differences exist between males and females in regards to Eating Concerns and Family Distress A Univar iate ANOVA was conducted to determine the relationship between gender, f amily d istress and e ating c oncerns RESULTS: The findings of this study report that eating concerns are significantly related to family distress in college students. F emales have higher eating concerns and family distress than males. The interaction between gender and family distress had a s tatistically significant effect on eating concerns.
11 CHAPTER 1 INTRODUCTION Overview An overall increase in e ating d isorders among youth in the United States has led to concern among parents and clinicians alike. Similarly, the increase in b ody i mage d issatisfaction has been a major concern, especially among females as studies have shown that it can lead to disordered eating and e ating d isord ers (Cook Cottone & Phelps, 2003) body di ssatisfaction, which in turn increases the risk for eating pathology (Stice, & Shaw, 2002). ls may benefit from focusing on body dissatisfaction and other sociocultural factors to treat and prevent eating disorders a mong youth. Studies have shown that women are more at risk for body dissatisfaction disordered eating, and its associated symptoms than men overall ( Ata, Ludden, & Lally, 2007 ; Abebe, Lien, & Von Soest, 2012 ; Blackmer, Searight, & Ratwik 2011; Hughes & Gu llone, 2011; Hayman et al. 2007 ). Nonetheless, men account for 5 15% of patients with anorexia or bulimia and an estimated 35% of those with binge eating disorder thus still warrant investigation ( Males and Eating Disorders 2008 ). For men two distinct body image concerns are body fat and muscularity and the pressure to increase muscle mass is prevalent, even at a young age ( Tylka, 2011 ; Ricciardelli, McCabe, & Lillis, 2006 ; Shomaker and Furman, 2010 ). Studies have also shown that resiliency factors can prevent or reduce body image dissatisfaction such as a flexible view of beauty ( Holmqvist, & Frisn, 2012), spirituality (Hayman et al. 2007; Choate, 2007), self compassion (Wasylkiw,
12 MacKinnon, & MacLellan, 2012), self esteem (Hayman et al., 2007; Udall Weiner, 2009), and social support from family, peers, and/or the community ( Blackmer, Searight, and Ratwik 2011; Haworth Hoeppner, 2000; Choate, 2007 ). Social systems such as parents, peers, and the community can have either a positive or negative influence on body image and eating attitudes Parents and friends may help adolescents develop a positive body image, but they may also increase change their appearance ( Ata, Lu dden, & Lally, 2007 p.3 ). For e xample, what association if any, does family distress have to eating concerns among male and female college students? The purpose of this research study is to examine the relationship between e ating c oncerns and f amily d is tress in college students and assess whether there are any gender differences in regards to this relationship The following section is a review o f relevant literature concerning body image dissatisfaction and disordered eating The literature review also focuses on developmental factors, gender differences and family influence on body image dissatisfaction, disordered eating and eating disorders Literature Review Body image dissatisfaction is a prevalent issue as it can lead to disordered eating and a decrease in overall wellness (Mazzeo 1999; Sinclair & Meyers, 2004; Hughes & Gullone, 2011). Family influence can play a part in affecting how people feel about themselves and in turn about their body image F amily influence can ei ther positively or negatively affect body image and eating concerns. Lastly, the relationship between gender, eating concerns, and family factors will be reviewed. These concepts will be described below.
13 Body Image Dissatisfaction Mazzeo (1999) stud y fou nd that in a sample of 302 female undergraduate volunteers, d isordered eating was significantly and more strongly related to body image preoccupatio n than to body image attitudes study shows the importance of body image attitudes and body image preoccupation and how they relate to disordered eating. Since disordered eating is a risk factor for e ating d isorders, this finding is relevant in showing how body image preoccupation may b e a risk factor for e ating d isorders. Sinclair and Myers (2004) found results on o bjectified body c onsciousness and how it affect ed wellness in 190 European American, heterosexual, female undergraduates age 19 21. The finding s show that negative body image in women can lead to a decrease in wellness, but also shows how appearance control can increase wellness. A female may feel that since she has control over her appearance, she can change her appearance to her preference, but if she lacks appearance contro l, she may be limited in this perspective if she has a negative body image. The selection of participants and self report bias are limitations to the study. (2005) study focus ed on nutrient intakes, body image perceptions, and weight conce rns of 123 female US international synchroni zed skaters ages 14 23. The skaters perceived themselves to be more over weight than they actually were and 84% reported to b ody s hape, 67 % wanted to be thinner than they were and in regards to b ody w eight, 89% wanted to weigh less than their current weight, with 24% wanting to lose 10 or more pounds. Poor physical self appraisal was associated with a greater discrepancy between the part current and ideal body image ratings. This study shows the
14 extra pressure that women who participate feel to have a certain body image as well as the perception of viewing themselves as heavier than they are. Hughes and Gullone (2011) studied 533 males and females ages 11 20 in Australia to assess whether emotion regulation (ER) has an effect on body image concerns and psychological symptoms ( i.e. drive for t hinness, b ulimic symptoms, d epression, and a nxiety) In this study, b ein g female predicted higher levels of all psychological symptoms and more frequent b ody i mage c oncerns also predicted higher levels of all psychological symptoms. Higher body mass index (BMI) significantly predicted a greater d rive for t hinness and b ulimic s ymptoms. Greater i nternal d ysfunctional ER predicted greater b ulimic, d epressive, and a nxiety s ymptoms. Greater e xternal d ysfunctional ER predicted higher levels of b ulimic and d epressive s ymptoms. This article discusses the possible role of emotion regula tion in regards to body image concerns and other psychological symptoms in males and females. Development of Body Image Dissatisfaction and Eating Attitudes Adolescence involves a time when children are growing into new bodies and beginning to develop thei r own identities. Abnormal eating risk usual ly peaks around mid adolescence, especially in females ( Abebe, Lien, & Von Soest, 2012 ). Around the a distribution of fat around the hips and thighs, which is developmentally appropriate, but conflicts with cultural ideals of beauty in the U.S. (Dittmar et al. 2000; Levine & Smolak, 2002 ). Unfortunately, girls are not aware that this body type is developm entally appropriate and 15, girls reported greater dissatisfaction with their profiles, legs, hips, thighs, and faces Boys pla ce a larger importance on increasing
15 muscle size and perceive a greater pressure to increase their muscles (Ricciardelli, McCabe, & Lillis 2006). Looking at adolescent development for both women and men is important in understanding the beginning of body image dissatisfaction and how environmental influences affect them. A dolescents than adults for severe psychological consequences if body image problems are not dealt with properly. Whetstone, Morrissey and Cummings (2007) studied 5,174 middle school students ages 10 16 in North Carolina to assess the relationship between perceived weigh t status and suicidal ideation The Youth Risk Behavior Survey for middle school students was used and incorporated t hinking, planning, and attempting suicide. More females than males reported thinking, pla nning, and attempting suicide. In males, being underweight was significantly associated with all three categories of suicide ideation. Perceiving oneself to be overwei ght was significantly related to suicidal thoughts and actions for both boys and girls when controlling for personal and family characteristics. No significant differences were seen in regards to race. A limitation of reported e thnicity was the lack of cho ices: African American, White, or Other. This study shows the possible risk of suicide in regards to body image in middle school, especially in females. More research is needed to assess differences in ethnicity. Abebe, Lien, and Von Soest ( 2012 ) followed 3,150 Norwegian males and females for 11 years covering the age span from 14 to 33 years to investigate age related trends in bulimic symptoms and associated risk factors Females had higher levels of bulimic, depressive, and anxiety symptoms and lower lev els of appearance satisfaction than males at all ages. Females ha d a high risk for bul im ic behaviors at mi d
16 adolescence yet their level s of bulimic, depressive, and anxiety symptoms decrease d with age as their level of appearance satisfaction increased F or males, bulimic symptoms show ed a decline from age 14 to mid adolescence and then a slight increase, leveling off in the early 20s. Participants with a higher Body Mass Index experienced significantly more symptoms. BMI, appearance satisfaction, and symp toms of anxiety and depression are significant predictors of bulimic symptoms for both genders This study shows differences in gender in regards to the development of bulimic symptoms and body image attitudes. Malt by, Giles, Barber, and McCutcheon (2005) studied 229 adolescents age 14 16, 183 undergraduates age 18 23, and 289 adults age 22 60 form north England to assess whether intense personal celebrity workshop is related to body image. Adolescents had the highest scores on the Celebrity Attitude Scale. Intense personal celebrity worship was related to poorer body image for adolescent females. A dolescent females are the most susceptible to sociocultural influences and it can negatively affect body image in regards to this study Ricciardelli, McCabe, and Lillis (2006) found in a sample of 237 boys ages 8 11 in Australia, that a pproximately 1/3 engaged in weight loss strategies, while approximately 1/2 engaged in muscle gaining strategies. Drawings indicated that 47.4% of the boys des ired a thinner body size and 20.7% desired a larger body size. Over Fifty eight percent rated their weight as important and 59.5% rated their muscles as important. A higher BMI was associated with higher levels of body dissatisfaction and strategies to dec rease weight, whereas lower BMI predicted the greater importance placed on muscles. Lower levels of self esteem predicted higher
17 weight loss thoughts and actions. Higher levels of perceived pressure were associated with greater body image concerns and body change strategies Perceived pressure to increase muscles was a more important predictor than perceived pressure to lose weight. Research has shown that body image dissatisfaction is prevalent in adolescence and can lead to more severe consequences such a s disordered eating and suicide. Males place importance on gaining muscle even at a young age ( Ricc iardelli, McCabe, & Lillis, 2006 ). Self esteem and certain sociocultural influences have shown to only be a weak pr edictor of body image concerns, thus more research is needed to assess the role of self esteem and sociocultural factors in relation to body image and eating concerns. Gender Differences Though there is an emphasis on females and eating disorders, there are males who also struggle with eating disorders and body image dissatisfaction Men and boys are bombarded with media images of muscular (mesomorphic) men without realizing that this ideal physique can only be attained with the use of anabolic steroids (Stout & F rame, 2004). Airbrushing may also be used to create this unattainable body in advertising Unfortunately, many boys have developed an eating disorder or an image disorder such as muscle dysmorphia by the time they reach adulthood (Stout & Frame, body size and muscularity, even if he already has a toned and muscular body (Stout & frame, 2004 c.i. Pope, Phillips, & Olivardia, It is therefore, important to look at gender d ifferences in regards to body image attitudes and eating concerns.
18 Shomaker and Furman (2010) studied 198 male and females ages 16 19, which were ethnically representative of the U.S. population and found that male s had higher scores than female s on drive for muscularity preoccupation with muscularity and pressure to be muscular from romantic partners. Females scored higher than males on all disordered eating symptoms. C lose relationships such as those with parents, friends, and romantic partners appear to have significant and behaviors related to pursuit of muscularity. This study shows the importance of including muscularity dissatisfaction regarding body image, especially in regards to men and how pressure from friends and family impact body image and behavior. Looking at differences in body fat dissatisfaction, muscularity dissatisfaction, and disordered eating in regards to homosexual and heterosexual college men ages 17 23, Smith, Hawkeswood, Bodellm and Joiner (2011) found that homosexual men reported higher levels o f disordered eating and more body fat dissatisfaction than heterosexual men. Heterosexual men reported more muscular ideals for themselves than the homosexual men did, but did not differ in what they believed their potential partners found attractive. Heterosexual men desired a more muscular figure than they thought a potential mate would want and homosexual men reported that a potential mate would want them to be leaner than they would ideally like to be. Body fat but not muscularity dissatisfaction predicted increased dietary restraint, eating, and weight concerns in both groups of men. Body fat dissatisfaction also predicted disordered eating and concerns about shape in homosexual men. L imitation s of this study were the convenience sample and the fact that the two groups were collected through different means. This study
19 shows the prevalence of body image dissatisfaction in men, how it relates to disordered eating, and differences between men depending on sexual orientation. McFarland and Petrie (2012) found similar results in their study involving 189 male undergraduates ages 18 22 in study 1 and 188 male undergraduates ages 18 22 in study 2 to assess the psychometric properties of the 25 item Body Parts Satisfaction Scale for Men (BPSS M) which yielded reliable and valid scores. T here were s mall to moderate correlations with the measures of disordered eating, muscularity attitudes and behaviors, negative affect and mo od, and psychological well being. Body dissatisfaction was related to higher levels of bulimic and depressive symptoms, intention to engage in dietary restraint, hostility, and guilt. Men who were weight satisfied had significantly higher levels of psychol ogical wellbeing. Udall Weiner (2009) studied 172 homosexual men ages 18 79 to assess the relationship between self esteem, body image and sexual identity develo pment. In the White sample, identity stage was positively correlated with b oth self esteem and body image. S elf esteem and body image were also correlated with each other, yet s elf esteem did not adequately account for changes in body image for Whites For the ethnic minority group, self esteem was significantly relate d to body image. Limitations to the study included the lump ing together of all minorities and the G ay I dentity Q uestionnaire used is not appropriate for diverse populations. Though more research is needed, there is evidence of a relationship between body image and self esteem in homosex ual men. Wiseman and Moradi (2010) studied data from 231 particip ants who self identified as men (97%) or transgendered (2%) and as exclusively gay, mostly gay or bisexual to assess the relationship of sociocultural and psychological correl ates of
20 eating d isorder symptoms The men in the study reported having eating problems When controlling for BMI and age, p artial correlations were found among sexual objectification experiences, internalization of cultural standards of attractiven ess, body surveillance, body shame, and eating disorder symptoms. I nternalization of the cultural ideal had a significant positive indirect relation with body shame through body surveillance, and body surveillance had a significant positive indirect relati on with eating disorder symptoms through body shame. B ody surveillance mediated the link of internalization with body shame and body shame mediated the link of body surveillance with eating disorder symptoms. Harassment for gender nonconformity was linked with eating disorder symptoms through a positive set of relations involving internalization of cultural standards of attractiveness, body surveillance, and body shame. Limitations of this study include a lack of assessment for current experiences of harass ment and many of the instruments that were used were originally for women. Bottamini and Ste Marie (2004) studied 11 men age 18 25 with an average body mass index of 24.02 from Canada to explore male body image perceptions, motivations, and behaviors throu gh semi structured interviews Even though most participants desired a more muscular body (8 out of 11), many expressed a level of acceptance concerning how they looked. Many of the participants described the ideal to be tall, muscular, and lean and their perceived image selections for the media ideal, peer ideal, and mate ideal were similar, though not the desired body type for the participant. A limitation of this study is the small sample size and lack of clarity seen in the results.
21 Tylka (2011) study found that d issatisfaction with muscularity slightly predicted predicted disordered eating behaviors in 473 undergraduate men ages18 to 42 Family and me dia pressures to be mesomorphic predicted internalization of the mesomorphic muscularity enhancement behaviors through internalization of this ideal. Perceived pressure from friends to be mesomorphic seems to be directly associated with increased muscularity dissatisfaction for men. Body fat dissatisfaction fully accounted for the relationship between internalization of the mesomorphic ideal and disordered eating behaviors. Th is study shows the importance of viewing both body fat and muscularity dissatisfaction in men and how pressure from friends, family, and the media impact body image and behavior. A limitation of this study was the lack of reported appearance comparison fro m the participants Research has shown that in regards to men, two distinct body image concerns are body fat and muscularity ( Tylka, 2011; Smith Hawkeswood, Bodellm & Joiner 2011 ; Ricc iardelli, McCabe, & Lillis, 2006 ). Male s ha ve a higher drive for muscu larity preoccupation with muscularity and pressure to be muscular from romantic partners than females (Shomaker & Furman, 2010) Also, research has shown that homosexual and heterosexual men have differing body image concerns, especially in relation to t heir partners ( Smith, Hawkeswood, Bodellm & Joiner 2011 ). Pressure from family to have a mesomorphic body increased body image and muscularity enhancement behaviors in men (Tylka, 2011), yet more research is needed. Research has not been able to clearly show whether ethnicity plays a part in mal e bo d y image and eating concerns nor
22 whether the family environment (rather than direct pressure about appearance) influences body image and eating concerns. Family Influence The family system, cultural differences with their particularly in the form of positive feedback and encouragement may serve to buffer some of the more negative sociocultural influ ences, and help adolescents develop and maintain a positive body image over time (Bearman et al. 2006; Ricciardelli et al. 2000; Stice & Whitenton, 2002 as cited in Ata, Ludden, Choate has a similar view in her Body Image Resilienc e Model with five protective factors for girls; one being Family and Peer Support (2007). Family qualities such as supportive parental relationships, open communication and expressiveness, and low family stress can also protect against adolescent body ima ge dissatisfaction (Barker & Galambos, 2003; Graber, Archibald, & Brooks Gunn, 1999; Haworth Hoeppner, 2000; Kearney Cooke, 2002; Striegel Moore & Cachelin, 1999, as cited in Choate, 2007). On the other Relationships with parents that are more confl ict ridden and less warm and supportive are predictive of increased dieting and lower body image (Archibald et al 1999 as cited in Ata, Ludden, & Lally, 2007, p.3 parents, if positive, can be a protective factor, but if negative it can become a risk factor. Family s ystem Mei Ru Chao (2011) studied 453 families from Taiwan with children ages 8 11 to examine eight interaction relationship types; empathy, constraint, compromise, acquiescence, conflict, camouflage, indif ference, and defensiveness Mothers were found to express more empathy than fathers in a family interaction relationship. Children show more constraint, compromise, and acquiescence than
23 parents, which all contribute to a harmonious family interaction rela tionship. This study shows the importance of maintaining harmony in the Taiwanese family relationship, even if it involves internalizing anger, which can be damaging to the person holding it in. This study also shows how the children in these families valu e the family system. Edgar Smith and Wozniak (2010) studied 72 European American, suburban, church going, upper middle class families and their family values system in order to assess what values are prioritized and whether value agreement changed through out adolescent development. The families consisted of a mother and father with 1 6 children. The focus of the study w as on the three adolescent groups which were 24 adolescents age 12 13, 24 adolescents age 14 16, and 24 adolescents age 17 18. The results showed high scores on Indi vidualism and Equality Matching and f amily agreement was high throughout all adolescent stages. A limitation of the study was the removal of a mother because she was an outlier; because the study focuses on the family system, the entire family should have been removed. Also, the convenience sample may have included families that were cohesive. It is possible that other less cohesive families chose not to volunteer for fear of exposing their family. This study shows how family value s can be stronger than peer influence in adolescents from European American, suburban, church going, upper middle class families. Coomber and King (2008) studied 47 Australian sister pairs ages 18 25 to assess perceived family modeling and pressure, social comparison, body image dissatisfaction (BID) and eating behaviors by both sisters. Participants perceived equally significant modeling cues from mothers and sisters, though they perceived differential degrees of modeling and pressure from each other. Sisters were a
24 significantly stronger modeling agent than fathers. Both sisters were more likely to use sisters and peers as social comparison targets than parents and viewed them as more influential. Sisters and peers were equally important comparison targets. Sisters were correlated on measures of BID, drive for thinness, d ietary restriction, bulimic behaviors, perceived mother and father pressure, and perceived mother and father modeling. Familial modeling did not significantly predict BID. The relationship of father and sister pressure on BID was partially mediated by inte rnalization and social comparison. The relationship of mother pressure on BID was fully mediated by internalization and social comparison. Sister modeling had a direct effect on dietary restriction and bulimic behaviors. This study shows the importance of mother and sister influence on girls. A limitation of this study is self reported bias and the possibility that sisters worked on the questionnaires together, though they were told to work on them separately. Parenting Blissett, Meyer, and Haycraft (2011 ) focused on 77 mothers of children 3 8 years old in the UK to assess whether eating and behavior problems are partly due to parenting. Pressure to eat was associated with less enjoyment of food, slower eating, more peer problems and total behavioral probl ems. Restriction of food was associated with more emotional overeating, greater hyperactivity and behavioral problems. Conduct disorder symptoms were associated with greater food fussiness. Permissive parenting was associated with greater food fussiness, conduct problems, hyperactivity and total behavior problems. Once parenting style and feeding practices were controlled for, no significant relationships between eating and behavioral problems were seen. A limitation to the study includes a lack of a follo w up. This study shows how
25 parenting can influence eating and behavior problems even at a young age, which can lead to more problems in adolescence. Cheng and Mallinckrodt (2009) found that mother care was associated with body image dissatisfaction in a sa mple of 224 females at a public university. Mother care and father care were significantly ass ociated with anxiety attachment Anxiety a ttachment was linked to media internalization, which was linked to Body Image Dissatisfaction. Limitations of this study include a sample bias based on choosing specific classes and a poor representation of diversity. This study is relevant in that parental care can lead to anxiety, which can lead to Body Image Dissatisfaction. Lobera, Rios, and Casals (2011) focused on 70 (10 men and 60 women) Eating Disordered (ED) outpatients in the Institute of Behavioral Sciences in Spain. In regards to Perceived Neglectful Parenting, paternal parenting lead to the highest scores in bulimia and body dissatisfaction in ED patients and ma ternal parenting lead to more social withdrawal in ED patients. The most common parenting style for ED patients was low care, high control. In regards to Perceived Affectionless Control, both paternal and maternal parenting lead to highe r scores in depress ion in the ED patients with paternal care leading to more trait anxiety and maternal care leading to higher scores in avoidance and problem during treatment for some patients Ethnicity was never mentioned and there were significantly more women than men in the study. This study shows how parenting styles can a ffect ED patients. Nollen et al. (2006) studied 265 Black and White adolescents age 10 19 from an urban pediatric clinic and found that Idea l Body Size (IBS) for White girls and White
26 boys was significantly related to parental expectation and I BS for Black girls was significantly related to peer norm and peer ideal. For Black boys IBS was influenced by their perceptions of their appearance, peer ideal, parent perception, and depressive symptoms. Black adolescents adopted heavier body image ideals compared to White adolescents. All adolescents expressed body dissatisfaction as most girls wanted to be smaller and most boys la rger than their current size. A limitation to the study was the convenience sample and the samples for each group were not balanced (i.e. 24 White boys and 116 Black g irls). This study is relevant as it shows some cultural and gender differences in regards to IBS as well as the importance of parental perception and expectation, and peer influence. Similarly in regards to parental expectation, Gardner et al. (1997) found that related to their level of body dissatisfaction ( Ricciardelli, McCabe, & Lillis, 2006). Family e nvironment Ata, Ludden, and Lally (2007) found that females age 13 19 at high risk for eating concerns reported less parental support, lower self esteem, and lower body esteem than did lower risk females. Males age 13 19 at high risk for eating concerns reported less parental support and more pressure from family and friends to gain muscle than did lower risk males. Females reported more body dissatisfaction and negative eating attitudes and behaviors than males, though males wanted to gain more upper body weight/muscle than females. Females also reported higher peer support, teasing from family about weight, pressure from friends and family to lose weight, and media pressure. M ales reported higher self esteem and more pressure from friends and family to gain muscle than females. Adolescents reporting lower levels of peer support and more teasing from family about weight reported lower
27 body esteem and were more likely to report t hat their actual body/figure was larger than their ideal body/figure Minority adolescents and adolescents reporting low self esteem were more likely to report negative eating attitudes and behaviors. The most salient predictor of negative body image and e ating attitudes and behaviors was perceived family pressure to lose weight as reported by adolescents. A limitation of this study is the small sample size. Blackmer, Searight, and Ratwik (2011) studied 103 college varsity athletes (47 males and 56 females ) age 18 25 to assess the relationship between eating attitudes and behav iors and perceived family of origin climate. Similar to the study by Ata et al f emales reported more negative eating attitudes and behaviors and body image issues than did males. However, t here was no gender difference in perceptions of family climate. There was a moderate association between the perception of the family of origin as discouraging individual autonomy and disorde red eating as well as a strong association between perc eived family of origin climate and body image dissatisfaction. Students that rated their families as promoting open, responsible expression of emotions and ideas while respecting individual family members were less likely to report bulimic behavior and pre occupation with food, body image, and dieting. A limitation of this study is that the results are based on self reports rather than observed family of origin climate and the results are mainly based on mostly White European students. Kluck (2010) studied 2 68 college women age 16 24 with a mean BMI of 22.5, which had, on average, lived with their parents less than one year prior to the study to assess family influence on disordered eating. Parental comments and family focus on appearance were significantly a ssociated with body image dissatisfaction and bulimic
28 symptomology. More frequent comments predicted greater difficulties in daughters even when comments as encouragement. Body image dissatisfaction parti ally mediated the relation appearance and control weight and/or size was a stronger predictor of daught c ontrol weight and/or size and body image dissatisfaction was the strongest relationship between any other type of commentary and body image dissatisfaction This relationship was also a significantly better predictor of body image dissatisfaction than both parental criticism and parental teasing. This study shows the influence of parental comments, especially those directed from mother to daughter, about weight on body image and eating behaviors. Sira and sample of college students, parental control was associated with eating disturbances among males but not among females However, the study also found that that excessive parental control has to increased dieting behavior. Also, m aternal control was a significant predictor o f body satisfaction in females. Granberg Simons, and Simons (2009) studied 256 African American females age d 10 15 from a longitudinal data set to assess whether they have generally positive self images when compared to other ethnic groups and how family racial socialization influences self image. Being of large body size is not related to social self image until ages 14 15. There is an association between parental evaluatio ns of respondent
29 social skills and their social self image. Among girls living in neighborhoods where the percentage of African American residents is relatively high, there is little difference between the social self image of larger versus smaller adole scent girls However, among girls living in neighborhoods where the percentage of African Americans is lower, larger girls are more likely to report a less positive social self image when compared to smaller girls. The results suggest that active racial so cialization within the home does mitigate the influence of a large body size on social self image. A l imitation Haworth Hoeppner (2000) interviewed 30 White middle class women ages 21 44 (9 without an E ating D isorder 11 diagnosed with an E ating D isorder and 10 self diagnosed with an E ating D isorder ) on body image and eating problems to explore how family influences cultural ideas on thinness. Four themes emerged as impo rtant factors in the production of eating disorders which were: a critical family environment, coercive parental control, an unloving a parent child relationship, and a main discourse on weight present in the home. Among the women with eating disorders, th e most common pattern (n = 9) is the presence of all four themes. The absence of those themes is the most common pattern (n = 6) found among women without eating disorders. Only women with eating disorders described family environments that were both criti cal and contained a main discourse on weight This study shows how the family environment can influence cultural idea l s o f thinness in women and lead to the development of eating disorders Similar results were found in Gillett, Harper, Larson, Berrett, and Hardman (2009) study which found that in a sample of 102 families with a young adult female
30 diagnosed with and eating disorder (N=51) or without an eating disorder (N=51 ), eating disordered families had more constraining family rules than non eating disordered families. Also, females with an eating disorder reported a lower propor tion of facilitative family rules and a higher proportion of constraining family rules than did parents and siblings. In sum, r esearch has shown that in some families paren tal or familial influence holds the same or more weight than peer influence ( Edgar Smith & Wozniak 2010; Coomber & King, 2008; Ata Ludden, & Lally, 2007; Nollen et al., 2006) Parenting style can affect eating problems even at a young age ( Blissett, Meyer, & Haycraft 2011 ) Black adolescents adopted heavier body image ideals compared to White adolescents ( Nollen et al. 2006) In regards to African American females, active racial socialization within the home lessen s the influence of a large bo dy s ize on social self image Mothers and fathers have been shown to influence body image dissatisfaction and disordered eating in females, but little research h as shown this effect for males ( Lobera, Rios, & Casals, 2011 ; Cheng & Mallinckrodt 2009 ; Kluck, 2010; Haworth Hoeppner, 2000 ; Gillett, Harper, Larson, Berrett, & Hardman 2009 ) Blackmer, Searight, and Ratwik (2011 ) study showed that even though there was no gender difference in perception of family climate, f ema les reported more negative ea ting attitudes and behaviors Family pressure has also shown body image dissatisfaction in both males and females, but in regards to males there was pressure to increase muscle size ( Ata, Ludden, & Lally, 2007; Tylka, 2011) It is important to note that the sample sizes in the latter two studies are small, thus more research is needed.
31 Summary of Relevant Literature According to the literature, body image dissatisfaction and eating attitudes and behaviors in females is an issue n ot only because it can lead to e ating d isorders, but it can also lead to depression suicide ideation, and suicide. can also put them at risk for disordered eating and engaging in possibly dangerous musc ular enhancement. The literature has shown the influence of perceived family and peer pressure for both genders though more research is needed Developmental and contextual factors might cause adolescent girls to be the most susceptible to family, peer and other social (e.g. media ) influence Fortunately resiliency factors also can prevent or buffer body image issues such as having a flexible view of beauty, media literacy, self compassion, self esteem, social support, peer support, having supporti ve f amily values, proper parenting, and having a positive relationship with parents, especially mothers. Aim of Study and Research Questions Body image dissatisfaction and disordered eating has shown to be risk factor s for eating disorders and a lack of we llness in both men and women. Family factors have a differential influence on body image, eating attitudes and behaviors for both men and women depending on the nature of the relationship Also, though some studies do include gender differences in regards to family influence, more research is needed. Does family influence body image issues and eating concerns in college aged men and women ? The purpose of this study is to determine whether college students eating concerns are related to family distress Als o, gender differences in regards to eating concerns and fa mily distress will be examined.
32 Research Questions 1. Is there a relationship between family distress and eating concerns in college students? 2. Do males, females, and transgendered students differ on eating concerns? 3. Do males, females, and transgendered students differ on family distress? 4. Does the interaction between gender and family distress have a significant effect on eating concerns?
33 CHAPTER 2 METHOD Sample The data for this study was comprised of approximately 3 years (20 0 9 2012) of de identified client data including 9,903 undergraduate and graduate students at the University of Florida ( 6359 female, 3421 male and 16 transgender ) who accessed the ompleted the Counseling Center Assessment of Psychological Symptoms (CCAPS 62). Twenty six of the 9,90 3 students the sample set at 9,877. The original data set consis ted of 71% White, 11.8% African Ameri can/Black, 18.3% Hispanic, 10.1 % Asian, 1% American Indian or Alaskan Native, 0.9% Native Hawaiian or Other Pacific Islander, and 10.4% did not report ethnicity. Procedures After receiving approval from the Institutiona l Review Board 02 permission to access archival data was granted from the University of Florida Counseling and Wellness Center on the Counseling Center Assessment of Psychological Symptoms (CCAPS 62). The CCAPS instruments were developed using a balanced rational/clinical approach and are intended to meet the clinical, research, and administrative needs of the counseling center field while also contributing valuable information to the science of mental health in college students (User Manual, 2010). All students that complete the CCAPS 62 are given an informed consent which ask s the students whether they agree to contribute their anonymous numeric data for research purposes. This numeric data is de ident ified and there are no potential risks because the database is confidential and archival.
34 Measures A secondary data set was used for the study. The CCAPS is a 62 item instrument with eight subscales that measure psychological symptoms or distress in co llege students ( Center for Collegiate Mental Health 2010) The eight subscales include : (1) Depression, (2) Generalized Anxiety, (3) Social Anxiety, (4) Academic Distress, (5) Eating Concerns, (6) Family Distress, (7) Hostility, and (8) Substance Use. Th e CCAPS 62 takes approximately 7 10 minutes to complete and is usually used for initial and post treatment assessments though it can also be used to monitor ongoing treatment (User Manual, 2010) For the p urpose of this study the two subscales: Eati ng Concerns and Family Distress will be used. The Eating Concerns subscale consist s of 9 statements which include tems on the Family Distress subscale consist s My family is basically a happy one (reverse scored) See F igure 2 1 for all the items under these two subscales. These statements a re scored by a Likert scale from 0 A single item was used to measure gender; participants identified themselves as male, female, transgender Some students chose not to answer this question at all. Body image issues were not distinguished from eating concerns in this study. It is difficult to distinguish body image from eating concerns using the CCAPS 62 Subscale Two items on the subscale
35 could have been categorized as either body image or eating concerns which we Therefore, the eating concerns total scale was used in this study Figure 2 1. CCAPS 62 Eating Concerns and Family Distress items Data Analysis Gender and two subscales from the CCAPS 62 ( Eating Concerns and Family Distress ) were used as variables in this study A c orrelational a nalysis will be used to determine the relationship between the latter two constructs Eating Concerns will be measured using the CCAPS 62, 9 item subscale Eating Concerns. Family Distress or Family Concerns will be measured using the CCAPS 62 6 item subscale Family Distress The data set w as analyzed using the Statistical Package for the Social Sciences (SPSS). The c entral tendency of the Eating Concerns and Family Distress subscale
36 was calculated A Pearson product correlation analysis was conducted to determine whether there is a correla tion between E ating C oncerns and F amily D istress A O ne way Analysis of Variance (ANOVA) was conducted in order to see whe ther male, female, and transgendered students differ in regards to family distress and eating concerns respectively Tukey post hoc comparisons of the three gender groups were conducted to determine where the differences lie in regards to family distress a nd eating concerns. A Univariate ANOVA was conducted to determine the relationship of g ender, f amily d istress and e ating c oncerns. Research Hypotheses The following null hypotheses will be examined in this study: There is no relationship between college concerns. There is no difference between college students, who identify as male, female, or transgendered and family distress. There is no difference between college students, who identify as male, female, or transgend ered and eating concerns. The interaction between gender and family distress does not have an effect on eating concerns.
37 CHAPTER 3 RESULTS Initially, the sample consisted of 9,903 students. Students that did not fully complete the items of the CCAPS 62 being used for this study were removed from the sa mple, leaving a remainder of 9, 6 82 students. As hypothesized the Pearson Product correlation analysis determined that t here was a significant positive correlation between eating concerns and family distres s r ( 96 8 2 ) =. 220 p < .001. This correla tion indicates that people who have increased eating concerns also tend to have increased family distress The Pearson Product correlation analysis also determined that there was a significant positive correlation between gender and eating concerns r ( 9595) =.218, p < .001 and gender and family distress r ( 9595) =.111, p < .001. Th e latter correlation s indicate that people of a certain gender also tend to have increased eating concerns and family distress respectively. O ne way ANOVA was conducted in order to see whether male, female, and transgendered students differ in regards to family distress (see T able 3 1) Family distress scores differed significantly among the three gender categories, F (2, 9592) = 59.42, p < .001 Tukey post hoc comparisons of the three groups indicated that females ( M = 2.20) reported significantly higher family distress than males ( M = 2.08), p < .001. However, there were no statistically significant difference s between male and transgendered students, p = .178 as well as female and transgendered students p = .636. It is important to consider that group sizes are unequal and hence r esults regarding transgendered students may not be valid. One way ANOVA was also conducted in order to see whether male, female, and transgendered students differ in regards to eating concerns. Eating concern scores
38 differed significantly among the three gender categories, F (2, 9592) = 240.26, p < .001 Tukey post hoc comparisons of the three groups indicated that females ( M = 1.06) reported significantly higher eating concerns than males ( M = 0.75), p < .001 Also, transgendered students ( M = 1.29) repor ted significantly higher eating concerns than males ( M = 0.75), p = .00 6. However, there were no statistically significant differences between female and transgendered students, p = .394 It is important to consider that group sizes are unequal and hence results regarding transgendered students may not be valid. U nivariate ANOVA was conducted to determine the interaction of gender and Family Distress on Eating Concerns (see T able 3 2) The interaction between gender and family distress was statistically s ignificant, F (1,29) = 2.06, p = .001. Table 3 1. One way ANOVA summary table ANOVA Sum of Squares df Mean Square F Sig. Family Distress Total Between Groups 31.496 2 15.748 59.415 .000 Within Groups 2542.373 9592 .265 Total 2573.869 9594 Eating Concern Total Between Groups 216.099 2 108.049 240.264 .000 Within Groups 4313.619 9592 .450 Total 4529.718 9594
39 Table 3 2. Univariate ANOVA summary table Tests of Between Subjects Effects Dependent Variable: Eating Concern Total Source Type III Sum of Squares df Mean Square F Sig. Corrected Model 434.968 a 57 7.631 17.773 .000 Intercept 79.999 1 79.999 186.325 .000 FamilyDisTotal 84.757 26 3.260 7.592 .000 Gender .818 2 .409 .953 .386 FamilyDisTotal Gender 25.617 29 .883 2.057 .001 Error 4094.749 9537 .429 Total 13203.568 9595 Corrected Total 4529.718 9594
40 CHAPTER 4 DISCUSSION The findings of this study report that eating concerns are significantly related to family distress in college students. Though the study does not focus on clinically diagnosed eating disorders, the eating concerns subscale provides information on students who are at risk for eating disorders. Since eating disorders are on the rise it is important for clinicians to assess r isk factors and resiliency factors in order to provide preventative and early treatment interventions According to the findings of this study, it is important to assess the family dynamic and how it affects the client when treating college students with e ating concerns. The study also reported that females have higher eating concerns than males which is consistent with previous research. Females also have higher family distress than males. Finally, the study reported that the interaction between gender an d family distress was significantly related to eating concerns. Comparison with O ther R esearch The results of the current study are consistent with Blackmer, Searight, and e family of origin and disordered eating as well as a strong association between perceived family of origin climate and body image dissatisfaction among male an d female university athletes Students that rated their families as supportive were less likely to report bulimic behavior and preoccupation with food and body image. However, Blackmer et al. also found no gender difference in perceptions of family climate which is inconsistent with t he results of this study ( females ha d higher family distress than males ) Haworth implies more specific yet consistent results in which women with eating disorders were found to have a more negative family
41 environment than women wi thout eating disorders. Gillett, Harper, Larson, Berrett, & that eating disordered families have less functional family rules than do non eating disordered families. Kluck (2010) found that parental comments and the focus of t he family on appearance were significantly associated with body image dissatisfaction and bulimic symptomology in college women. These findings are consistent with the significant correlation between family distress and eating concerns in this study. The f indings reporting that females have higher eating concerns than do males is consistent with previous research that reports that women are at more risk than men for body dissatisfaction eating concerns, and its associated symptoms ( Ata, Ludden, & Lally, 20 07; Abebe, Lien, & Von Soest, 2012; Blackmer, Searight, & Ratwik 2011; Hughes & Gullone, 2011; Hayman et al. 2007). The finding in the current study that females have higher family distress than males is less clear than the relationship between gender and eating concerns, yet is emales reported higher t easing from family about weight and more pressure from friend s and family to lose weight than males Findings o f this study also determined that the interaction between gender and family distress was significantly related to eating concerns which is consistent with Ata find ing that females in the high risk eating attitudes and behaviors group repor ted less parental support, lower self esteem, and lower body esteem than adolescents in the low risk group. The results of the current study are also consistent that shows both young men and women may develop eating
42 disorder sympt oms in response to family violence. Sira and showed that among a nonclinical sample of college students, parental control was associated with eating disturbances among males but not among females, which is inconsistent with the results of the current study (females had higher family distress than males). However, Sira and White (2010) also found that that excessive parental dieting behavior. Althoug h the interaction between gender and family distress on eating concerns is significant, how gender and family distress interact to cause this significance on eating concerns is unclear. Limitations The limitations of this study include the lack of demographic data on age and ethnicity. Alt hough ethnicity was reported on the overall sample, there was no data on the race or ethnicity of each student in the sample. The lack of data on age and ethnicity limits the results because they do not show whether differences in age or ethnicity would impact the results. Also, the sample size of transgender students (N=14) is very small and thus, is not as reliable as the sample size of male (N= 3324 ) and female (N= 6257) students Another limitation of the study is the fact that even though the correlation between eating concerns and family distress is significant, this correlation does not tell us whether family distress causes eating concerns, nor whether eating c oncerns causes family distress. This study is focused on the idea that family can influence the prevalence of body image issues and eating concerns. It is important to note though, that there may be other related factor s that caused the body image issues a nd eating concerns in the person, which then caused the family distress. Since the CCAPS 62 is a
43 self report instrument, it is prone to social desirability bias. Also, t he CCAPS 62 does not assess muscularity enhancement behaviors or pursuit of muscularity which is a significant difference in males and females regarding body image as seen in the study by Ata et al., 2007 T hus the definition of eating concerns in this study might have been As stat ed previously, b ody image issues were not distinguished between eating concerns in this study. It is difficult to distinguish body image from eating concerns using the CCAPS 62 Subscale Eating Concerns. Two items on the subscale could have been categorized as scale remained as a whole. Unfortunately, because this distinguishment was not made, it is unclear whether body image in itself is significantly correlated with family distress. Conclusion and S uggestions for F uture R esearch In summary, though the correlation between family distress and eating concerns is significant, the data do not clearly indic ate a cause and effect pathway. Further research needs to be done concerning the relationship between eating concerns and family distress as well as the relationship between body image dissatisfaction and family distress. There is still little researc h on men and transgendered individuals with eating disorders on and how they differ. M ore research needs to be done on how the impact of family differs between males, females, and LGBT individuals. Also, more research needs to be done on how family impacts individuals of various gender identities w it h eating disorders and those at risk for eating disorders (i.e. body image dissatisfaction and disordered eating).
44 In regards to men, it seems that assessments looking for body image dissatisfaction are more fo cused on women than men, and thus may be gender biased. only to losing body fat, but also to increasing muscle mass. Including questions related to increasing muscle mass a nd associated behaviors may allow for a clearer and more wholistic picture in assessing body and eating concerns for males. Another important area of future research is to assess differences in ethnicity in regards to eating disorders, body image dissatisf action, and disordered eating as cultural factors may be of influence. The impact of family is another important area to look at in regards to various cultural backgrounds with eating disorders, body image dissati sfaction, and disordered eating With a cle arer understanding of these gender and cultural differences, we can better assist clients with various backgrounds as clinicians. Research in Canada has shown the benefits of family based treatment with clients with eating disorders ( Robinson, Strahan, Gir z, Wilson, & Boachie, 2013; Couturier Kimber, & Szatmari, 2013). Couturier, Kimber, and showed that even though family based treatment and individual treatment for adolescents with eating disorders showed no differences during and at the end of treatment, family based treatment was superior to individual treatment at the 6 12 month follow up. Incorporating the family in treating individuals with eating disorders seems paramount especially since there is some evidence that family ba sed treatment is superior to individual treatment even one year after treatment. These results have implications for the prevention and early intervention of eating disorders in adolescents with body image issues and disordered eating behaviors. The negati ve health effects of
45 eating disorders can be severe especially if not treated (Hurst, Read, & Wallis, 2012). The prevention o f these possibly irreversible negative effects are our goal as clinicians. More research on resiliency factors in college students in regards to family can also be assessed to determine whether students with a positive family environment have less severe psychological symptoms (i.e. body image dissatisfaction, anxiety, depression, and disordered eating) than students with a negative family environment. It seems that looking at parental resiliency as well as the resiliency of the individual placed at risk are important areas of study. Robinson, Strahan, Girz, Wilson, and based treatment with adolescents with eating disorders showed that, throughout treatment, parental self efficacy increased and adolescent s s ymptoms decreased Maternal and paternal self efficacy scores also predicted adolescent outcomes throughout treatment. These findings are important in showing that parental resiliency factors may also influence adolescents at risk for eating disorders. In conclusion, the findings of this study suggest the importance of looking at family dynamics when treating students with eating disorders or those a t risk for eating disorders. Future directions of this study include examining family distress, body dissatisfaction, and eating concerns in students with various cultural backgrounds, ages, and gender identities
46 APPENDIX A CCAPS 62 SAMPLE PROFILE REPOR T
47 APPENDIX B CCAPS 62 SAMPLE TEST
49 APPENDIX C I NFORMED CONSENT
51 APPENDIX D IRB 02 APPROVAL LETTER
52 LIST OF REFERENCES Abebe, D., Lien, L., & Von Soest, T. (2012). The development of bulimic symptoms from adolescence to young adulthood in females and males: A population based longitudinal cohort study. International Journal o f Eating Disorders 45 (6), 737 745. Ata, R., Ludden, A., & Lally, M. (2007). The Effects of Gender and Family, Friend, and Media Influences on Eating Behaviors and Body Image During Adolescence. Journal Of Youth & Adolescence 36 (8), 1024 1037. doi:10.1007/s10964 006 9159 x Bardy, S. S. (2008). Lifetime family violence exposure is associated wi th current symptoms of eating disorders among both young men and women. Journal of Traumatic Stress 21 (3), 347 351. doi:10.1002/jts.20335 Blackmer, V., Searight, H., & Ratwik, S. H. (2011). The Relationship between Eating Attitudes, Body Image and Perceiv ed Family of Origin Climate among College Athletes. North American Journal o f Psychology 13 (3), 435 446. Blissett, J. M. (2011). The role of parenting in the relationship between childhood eating problems and broader behaviour problems. Child: Care, Hea lth & Development, 37 (5), 642 648. doi: 10.1111/j.1365 2214.2011.01229.x Bottamini, G., & Ste Marie, D. M. (2006). Male Voices on Body Image. International Journal of Men's Health 5 (2), 109 132. Center for Collegiate Mental Health (2010). CCAPS 2010 User Manual. University Park, PA Chao, M. (2011). Family interaction relationship types and differences in parent child interactions. Social Behavior & Personality: An International Journal, 39 (7), 897 914. doi: 10.2224/sbp.2011.39.7.897 Cheng, H., & Mall inckrodt, B. (2009). Parental bonds, anxious attachment, media internalization, and body image dissatisfaction: Exploring a mediation model. Journal of Counseling Psychology, 56 (3), 365 375. doi: 10.1037/a0015067 Choate, L. H. (2007). Counseling adolescen t girls for body image resilience: Strategies for school counselors. Professional School Counseling, 10 (3), 317 326. Retrieved from https://s earch.ebscohost.com/login.aspx?direct=true&db=aph &AN=25435720&site=ehost live Cook Cottone, C., & Phelps, L. (2003). Body dissatisfaction in college women: Identification of risk and protective factors to guide college counseling practices. Journal of Co llege Counseling, 6 (1), 80. Retrieved from https://search.ebscohost. com/login.aspx?direct=true&db=aph&AN=9744884&site=ehost live
53 Coomber, K., & King, R. M. (2008). The role of sisters in body image dissatisfaction and disordered eating. Sex Roles, 59 (1), 81 93. doi: 10.1007/s11199 008 9413 7 Couturier, J., Kimber, M., & Szatmari, P. (2013). Efficacy of family based treatment for adolescents with eating di sorders: A systematic review and meta analysis. International Journal Of Eating Disorders 46 (1), 3 11. doi:10.1002/eat.22042 Dittmar, H., & Lloyd, B. (2000). The "Body Beautiful": English Adolescents' Images of Ideal Bodies. Sex Roles 42 (9/10), 887 915. Edgar Smith, S., & Wozniak, R. H. (2010). Family relational values in the parent adolescent relationship. Counseling & Values, 54 (2), 187 200. Retrieved from https://search.ebscohost.com/login.aspx?direct=true&db=aph&AN=48854444&sit e=ehost live Granberg, E. M., Simons, L., & Simons, R. L. (2009). Body size and social self image among adolescent African American girls: The moderating influence of family racial socialization. Youth & Society 41 (2), 256 277. doi:10.1177/0044118X09338505 Gillett, K. S., Harper, J. M., Larson, J. H., Berrett, M. E., & Hardman, R. K. (2009). Implicit family process rules in eating disordered and non eating disordere d families. Journal of Marital And Family Therapy 35 (2), 159 174. doi:10.1111/j.1752 0606.2009.00113.x Haworth Hoeppner, S. (2000). The critical shapes of body image: The role of culture and family in the production of eating disorders. Journal o f Marriage a nd t he Family 62 (1), 212 227. doi:10.1111/j.1741 3737.2000.00212.x Hayman, J. W., Kurpius, S. R., Befort, C., Nicpon, M. F., Hull Blanks, E., Sollenberger, S., & Huser, L. (2007). Spirituality among college freshmen: Relationships to self este em, body image, and stress. Counseling & Values, 52 (1), 55 70. Retrieved from https://search.ebscohost.com/login.aspx?direct=true&db=aph&AN= 27245919&site=ehost live Hughes, E. K., & Gullone, E. (2011). Emotion regulation moderates relationships between body image concerns and psychological symptomatology. Body Image, 8 (3), 224 231. doi: 10.1016/j.bodyim.2011.04.001 Hurst, K., Read, S., & Wal lis, A. (2012). Anorexia nervosa in adolescence and Maudsley Family Based Treatment. Journal of Counseling & Development 90 (3), 339 345. doi:10.1002/j.1556 6676.2012.00042.x Kluck, A. S. (2010). Family influence on disordered eating: The role of body imag e dissatisfaction. Body Image 7 (1), 8 14. doi:10.1016/j.bodyim.2009.09.009
54 Lobera, I. J., Rios, P. B., & Casals, O. G. (2011). Parenting styles and eating disorders. Journal of Psychiatric and Mental Health Nursing 18 728 735. doi: 10.1111/j.1365 2850.2011.01723.x N ational Library of Medicine. (2008). Males and Eating Disorders. National Institutes of Health Medline Plus, 3 (2) 18 Retrieved from http://www.nlm.nih.gov/ medlineplus/magazine/issues/spring08 /articles/spring08pg18.html Maltby, J., Giles, D. C., Barber, L., & McCutcheon, L. E. (2005). Intense personal celebrity worship and body image: Evidence of a link among female adolescents. Br itish Journal of Health Psychology, 10 (Pt 1), 17 32. doi: 10.1348/135910704X15257 Mazzeo, S. E. (1999). Modification of an existing measure of body image preoccupation and its relationship to disordered eating in female college students. Journal of Counse ling Psychology, 46 (1), 42 50. doi: 10.1037/0022 0220.127.116.11 McFarland, M. B., & Petrie, T. A. (2012). Male Body Satisfaction: Factorial and Construct Validity of the Body Parts Satisfaction Scale for Men. Journal o f Counseling Psychology 59(2), 329 337. doi:10.1037/a0026777 Nollen, N., Kaur, H., Pulvers, K., Choi, W., Fitzgibbon, M., Li, C., Ahluwalia, J. (2006). Correlates of ideal body size among black and white adolescents. Journal of Youth & Adolescence, 35 (2), 276 284. doi: 10.1007/s10964 00 5 9024 3 Ricciardelli, L. A., McCabe, M. P., & Lillis, J. (2006). A Longitudinal Investigation of the Development of Weight and Muscle Concerns Among Preadolescent Boys. Journal of Youth and Adolescence 35 (2), 177 187. Robinson, A., Strahan, E., Girz, L. Wilson, A., & Boachie, A. (2013). 'I Know I Can Help You': Parental Self efficacy Predicts Adolescent Outcomes in Family based Therapy for Eating Disorders. European Eating Disorders Review 21 (2), 108 114. doi:10.1002/erv.2180 Shomaker, L. B., & Furman, W. (2010). A prospective investigation of interpersonal influences on the pursuit of muscularity in late adolescent boys and girls. Journal o f Health Psychology 15 (3), 391 404. doi:10.1177/1359105309350514 Sinclair, S. L., & Myers, J. E. (2004). The rela tionship between objectified body consciousness and wellness in a group of college women. Journal of College Counseling, 7 (2), 150 161. Retrieved from https://search. ebscohost.com/login. aspx? direct=true&db=aph& AN=15204104&site=ehost live Sira, N., & White, C. (2010). Individual and Familial Correlates of Body Satisfaction in Male and Female College Students. Journal of American College Health 58 (6), 507 514.
55 Smith, A. R., Hawkeswood, S. E., Bodell, L. P., & Joiner, T. E. (2011). Muscularity versus leanness: An examination of body ideals and predictors of disordered eating in heterosexual and gay college students. Body Image 8 (3), 232 236. doi:10.1016/j.bodyim.2011.03.005 Stice, E., & Shaw, H. E. (2002). Role of body dissatisfaction in the onset and maintenance of eating pathology: A synthesis of research findings. Journal of Psychosomatic Research 53 (5), 985. Stout, E. J., & Frame, M. (2004). Body Image Disorder in Adolescent Males: Strategies for Schoo l Counselors. Professional School Counseling 8(2), 176 181. Tylka, T. L. (2011). Refinement of the tripartite influence model for men: Dual body image pathways to body change behaviors. Body Image 8(3), 199 207. doi: 10.1016/j.bodyim.2011.04.008 Udall We iner, D. (2009). Sexual identity development and self esteem as predictors of body image in a racially diverse sample of gay men. Journal of Homosexuality, 56 (8), 1011 1029. doi: 10.1080/00918360903275419 Wasylkiw, L., MacKinnon, A. L., & MacLellan, A. M. (2012). Exploring the link between self compassion and body image in university women. Body Image, 9 (2), 236 245. doi: 10.1016/j.bodyim.2012.01.007 Whetstone, L. M., Morrissey, S. L., & Cummings, D. M. (2007). Children at risk: The association between pe rceived weight status and suicidal thoughts and attempts in middle school youth. Journal of School Health, 77 (2), 59 66. doi: 10.1111/j.1746 1561.2007.00168.x Wiseman, M. C., & Moradi, B. (2010). Body image and eating disorder symptoms in sexual minority men: A test and extension of objectification theory. Journal o f Counseling Psychology 57 (2), 154 166. doi:10.1037/a0018937 Ziegler, P. J., Kannan, S., Jonnalagadda, S. S., Krishnakumar, A., Taksali, S. E., & Nelson, J. A. (2005). Dietary intake, body imag e perceptions, and weight concerns of female US international synchronized figure skating teams. International Journal of Sport Nutrition & Exercise Metabolism, 15 (5), 550. Retrieved from https://search.ebscohost.com/login.aspx?direct=true&db= aph&AN=18447851&site=ehost live
56 BIOGRAPHICAL SKETCH Yanel A. De Miranda w as born in Miami, Florida. She graduated from Barba ra Goleman High School in 2006 and earned her B.S. in p sychology with a minor in a rt h istory at the University of Florida in 2010 Yanel began graduate school in the Counselor Education program at the University of Florida as a masters/specialist candidate in 2010. Yanel has been trained a s a phone counselor at the Alachua C ounty Crisis Center where she volunteered from 2008 2010. She was chosen to work as a counselor at Buchholz High School for her practicum by the Shands Pals Program where she co founded a teen support group in 2011. Yane l was also chosen to work as a counselor at the University of Florida Counseling and Wellness Center for her one year internship in 2012. Yanel will complete her degree in Mental Health Counseling at the University of Florida in spring 2013. She looks forw ard to her future career as a professional counselor.