Debra J Moorhead,1* Cecilia K. Stashwick,2 Helen Z. Reinherz,2
Rose M. Giaconia,2 Ruth M. Steigel-Moore,3 and Angela D. Paradis 2

1 Center for Alcohol and Addiction Studies, Brown University, Providence,Rhode Island
2 Graduate School of Social Work, Simmons College, Boston, Massachusetts
3 Department of Psychology, Wesleyan University, Middletown, Connecticut

Accepted 5 August 2002

Abstract: Objective: This study investigated early predictors for developing eating disorders by young adulthood in a community sample of women participating in a 22-year longitudinal study. Method: Twenty-one women were identified at age 27 with lifetime full or partial eating disorders. These women were compared with 47 women with no history of eating disorders on predictive factors form three broad domains. Results: The women with eating disorders had more serious health problems before age 5 and mother-reported anxiety-depression at age 9. At 15, mothers described them as having more behavior problems. Betore age 15, families of the eating disorder group had more histories of depression, eating problems and changes in family financial circumstances. Discussion: This study identifies early predictors distinguishing girls who develop eating disorders. Findings point to the need for continued research in the area of early health to comprehensively examine the biologic, behavioral, and environmental risks for eating disorders. © 2002 by Wiley Periodicals, Inc. In J Eat Disord 33: 1-9, 2003.

Key words: adolescent predictors; eating disorders; health problems; environmental risks.

INTRODUCTION

An extensive theoretical literature has described etiologic modes for eating disorders and several recent reviews have summarized the state of risk factor research (for reviews, see Crago, Shisslak, & Ruble 2001; Stice, 2001; Streigel-Moore & Cachelin, 2001). Longitudinal studies of community samples covering the period from childhood to adulthood offer the most promising means of identifying the salient predictors for eating disorders. Such studies can fill important gaps in existing research that has tended to survey limited samples (Attie & Brooks-Gunn 1989; Vohs, Heatherton, & Herrin,2001), cover relatively short time spans (Rosen, Comps, & Tacy, 1993), or focus on a limited number of hypothesized predictors (Button, Sonuga-Barke, Davies, & Thompson, 1996; Killen et al., 1996). The current study was designed to address some of these identified research needs.
Research has shown that the etiology is multifactorial, including genetic, personal vulnerability, familial, social, and cultural factors (Striegel-Moore & Cachelin, 2001). Family and twin studies have shown that eating disorders aggregate in families (for review, see Klump, Kaye, & Strober, 2001). Previously identified familial risk factors include parental psychopathology and childhood physical or sexual abuse (Fairburn, welch, Doll, Davies, & O’Connor, 1997; Lilenfield et al, 1998).
Studies of personal vulnerability factors have evaluated low self-esteem (Buttton, et al., 1996; Fairburn et al., 1997; Fisher, Schneider, Pegler, & Napolitano, 1991), impulsive behaviors (Fisher et al., 1991; Pine, Cohen, Brook, & Coplan, 1997; Wiederman & Pryor, 1996), and anxiety and depression (Fisher et al., 1991; Rierden & Koff, 1997; Zaider, Johnson, & Cockell, 2000). Most studies of this area, however, have employed crossectional designs, which are not as helpful in identifying predictors of a disorder (Kraemer at al., 1997).
Several prospective studies have focused on health and development. Some studies (Attie & Brooks-Gunn, 1989; Graber, Brooks-Gunn, Paikoff, & Warren, 1994) have suggested that girls who mature early and are physically larger than their peers are more predisposed to developing problems with eating. Another study also found that higher body mass index and earlier pubertal development predicted disordered eating in a community study of adolescent girls (Keel, Fulkerson, & Leon, 1997). Cnattingius, Hultman, Dahl, and Sparen (1999) found that very preterm birth and birth trauma were predictive of the development of anorexia nervosa in a prospective study of females in Sweden. Allen, Lewinsohn, and Seeley (1998) have shown that prenatal and perinatal health is related to later psychopathology.

*Correspondence to: Debra J.Moorhead, Ph.D., Center for Alcohol and Addiction Studies, Brown University, Box G-BH, Providence, RI 02912. Email: Debra_Moorhead@Brown.edu
Published online in Wiley InterScience (www.interscience.wiley.com). DOI 10.1002/eat.10105

© 2002 by Wiley Periodicals., Inc.

The current study took advantage of the availability of data that are unique in three ways. First, the data were collected from a large community sample over a 22-year period. Few studies have the capacity to look at data collected over that span of time, beginning in the early childhood of the participants and continuing into their adulthood. By examining data collected prospectively from a community population, the current study provides a description of the childhood and adolescent experiences of participants at several time points considered critical in the development of eating disorders. Second, the data were collected from two informants: mothers and respondents. These separate perspectives offer the opportunity to trace the development of eating disorders over time, beginning before the age of 5 and including mothers’ reports of prenatal complications and early childhood health. The third strength of this study takes a multidimensional perspective of risk over a length of time that is seldom found in the literature.

METHODS

Participants

The study population was drawn from the female participants of the Simmons Longitudinal Study. As described in detail elsewhere (Reinherz, Giaconia, Carmola Hauf, Wasserman, & Silverman, 1999), the original sample included all youth entering kindergarten in 1977 in one public school district participating in state-mandated testing of health, developmental, academic, and behavioral factors (N = 763). The school district was located in a predominantly White, working-class and lower middle-class (Hollingshead, 1971) community in the northeastern United States. Data were collected from multiple sources at seven time points between ages 5 (1977) and 26 (1998). Between 1977 and 1988, attrition occurred primarily in the early grades when students transferred from public schools to parochial and private schools. Because data collection occurred in school, youths transferring out of public school before the third grade were excluded from followup. Overall attrition for the 22-year period was 28% of youths remaining in the public school system through third grade. During the most recent round of data collection, conducted at age 26 (1998), 376 respondents (approximately one half of the total sample is female) participated in a structured diagnostic interview. A comparison of the participants who remained in the study at age 26 and those lost to follow-up revealed no significant differences on key demographic and clinical variables originally characterizing the cohort.
For the current study, a subset of female participants was selected from the total sample based on their scores on the Drive for Thinness subscale of the Eating Disorders Inventory (EDI; Garner, 1991), which had been administered to all participants at age 21 (1993). All women (n = 31) with scores of 12 or higher no th EDI Drive for Thinness subscale and a sample (n = 40) of women with Drive for Thinness scores below 10 were contacted to participate in the current study. These respondents were contacted and interviewed at age 27, approximately 1 year after the previous round of data collection with the entire sample. Of the 71 women selected for this study, 68 women (30 with higher EDI scores and 38 with lower scores) agreed to participate and 3 could not be contacted.

Instruments and Procedure

Diagnostic Assessment of Full and Partial-Syndrome Eating Disorders
At age 27, trained interviewers completed telephone interviews with all women in the subsample. The interview included the Eating Disorders Module of the Diagnostic Interview Schedule IV (DIS-IV; Robins, Cottler, Bucholz, & Compton, 1995) to assess lifetime and current disorders based on criteria in the 4th edition of the Diagnostic and Statistical Manual of Mental Disorder (DSM-IV; American Psychiatric Association, 1994). Respondents were identified as meeting either lifetime full-syndrome anorexia nervosa or bulimia nervosa, lifetime partial-syndrome eating disorder, or as having no history of a an eating disorder. We defined partial-syndrome anorexia nervosa as the presence of at least two of the four criteria for anorexia nervosa, in addition to having either a high (12 or greater) Drive for Thinness score at age 21 or some functional impairment from anorexia symptoms as assessed with DIS-IV at age 27. Partial-syndrome bulimia nervosa was defined as meeting at least Criteria A, B and D (recurrent episodes of binge eating, recurrent purging, and self-evaluation unduly influenced by body shape and weight, respectively) for bulimia nervosa. These definitions of partial-syndrome anorexia and bulimia nervosa are similar to others used in a recent epidemiologic study of eating disorders (Lewinsohn, Streigel-Moore, & Seeley, 2000).

Childhood and Adolescent Predictors
Health-related predictors included interviews with mothers when respondents were 5 years old. Mothers provided information about pregnancy complications and the early health problems of the respondent. Adolescent self-reports at age 15 assessed heigh and weight and age of menarche.
Regarding behavioral-emotional predictors, measures of behavioral-emotional functioning were gathered from self-reports and from reports from mothers at ages 9 and 15. Mother-rated behaviors at age 9 were obtained using the Simmons Behavior Checklist (Reinherz & Gracey, 1983), an instrument developed to assess emotional and behavioral functioning in youth. Two subscales were examined for this study: anxious-depressed behavior (x =. 82) and peer relations (x = .76). Self-report behavior ratings at that age were assessed with th Piers-Harris Children’s Self-Concept Scale (Piers, 1984). This 80-item self-report instrument measures child self-concept in five separate cluster areas. The two subscales examined for this study were anxious-depressed (x =.74) and popularity (x =.68). At age 15, the Child Behavior Checklist (CBCL: Achenback & Edelbrock, 1983) and the Youth Self-Report (YSR; Achenback & Edelbrock, 1987) were used to measure mother and subject ratings of internalizing and externalizing behavior problems, somatic complaints ("I feel dizzy", "Nausea, feel sick without known medical cause"), and thought problems ("I repeat certain acts over and over," "I have thoughts that other people would think are strange"). These subscales showed good reliability: internalizing (CBCL: x = .89; YSR: x = .88); externalizing (CBCL: x = .89; YSR: x = .86); somatic complaints (CBCL: x = .72; YSR: x = .76); thought problems (CBCL: x = .75; YSR: x = .72).

RESULTS

Sample Description

Twenty-one women were identified through the DIS=-IV Eating Disorders Module as having a lifetime history of full or partial-syndrome eating disorders. Of these, 9 women met lifetime criteria for anorexia or bulimia nervosa and 12 met lifetime criteria for partial-syndrome disorders. The average gap of onset reported was 16.48 years (SD + 4.5 years). Of the 21 women with full or parital-syndrome eating disorders, 7 reported an age of onset of 14 years or younger. Analyses comparing the full and partial-syndrome cases revealed no statistical differences on key demographic variables or psychosocial functioning in young adulthood. Therefore, the full and partial-syndrome eating disorder cases were combined into the eating disorder (ED) group for the current study. Forty-seven women had no history of an eating disorder and comprised the non-eating disordered (noED) comparison group.
As shown on Table 1, the ED and noEd groups were quite similar in terms of demographic characteristics at age 26. The two groups did no differ in ethnicity, educational level;, and marital, parental, or current employment status. However, the two groups

Table 1. Demographic characteristics at age 26

Eating Disorder No Eating Disorder
(n = 21) (N - 47)
_---------------- -------------------------

N % N % x 2

White 21 100.0 46 97.9 .45
Married 6 28.6 11 23.4 .21
Has children 3 14.3 7 14.9 .00
Completed High School 21 100.0 46 97.9 .45
Completed College 9 42.9 18 38.3 .13
Currently employed 20 95.2 39 83.0 1.9
Salary more than $30,000 annually 2 10.0 22 56.4 11.8***

***p < .001.

differ significantly in income level. The noED women were more likely to earn at least $30,000 annually.

Childhood and Adolescent Predictors for Eating Disorders

Health-Related Predictors
As shown in Table 2, the two groups differed significantly in early health indicators. Mothers of ED group were twice as likely to report having had complications with the pregnancy with their daughters than mothers whose daughters did no develop an eating disorder. Mothers of girls who later developed eating disorders also were significantly more likely to report that their daughters had health problems as infants and toddlers than were mothers of daughters without eating disorders. No group differences were found at age 15 on measures of age of menarche and body mass index (based on self-reports of height and weight).

Emotional-Behavioral Predictors
In the domain of emotional and behavioral predictors, we found group differences in the mother reports, but not in the self-reports, of behavior at age 9 and 15 (Table 3). At age 9, mother ratings indicated that the ED group was experiencing more problems with anxiety-depression than their non-eating-disordered peers. Age 9 self-reports, however, revealed no group differences on measures of anxiety-depression or peer relations. At age 15, girls’ self-reports again showed no significant

Table 2. Relationship between health-related risks and eating disorders by age 27

Eating Disorder No Eating Disorder
(n = 21) (N - 47)
_---------------- -------------------------

Health and Developmental Risk % SE % SE x 2

Age 5: mother reports
complications with pregnancy 20.0 9.2 4.3 3.0 4.13*
Health problems, age 7-18 months 30.0 10.5 6.5 3.7 6.53*
M SD M SD the value
Age 15: self reports
Body mass index 20.23 2.73 21.24 3.01 -1.25
Age of Menarche 12.53 .77 12.51 .80 .07

*p <.05 ** p < .01. ***p < .001.

Table 3. Relationship between behavioral-emotional risks an eating disorders by age 27

Eating Disorder No Eating Disorder
(n = 21) (N - 47)
_---------------- -------------------------
M SD M SD the value
Behavioral-Emotional Risk

Age 9: mother reports
Anxious depressed 12.12 4.15 9.46 2.72 2.42*
Peer Relations 9.21 1.51 8.39 2.56 1.55

Age 9: self reports
Anxious-Depressed 10.50 3.05 9.96 3.18 .65
Popular with peers 9.65 2.06 8.65 2.92 1.58

Age 15: mother reports (CBCL)
Externalizing problems 53.80 10.24 48.98 10.30 1.57
Internalizing problems 57.35 12.35 49.21 10.55 2.74**
Somatic complaints 60.95 8.20 56.02 5.71 2.82*
Thought problems 57.25 7.57 53.23 5.35 2.47*

Age 15: self-reports (YSR)
Externalizing problems 53.62 10.01 53.30 10.24 .12
Internalizing problems 52.95 7.91 50.11 9.67 1.20
Somatic complaints 55.38 5.85 56.24 7.11 -.48
Thought problems 56.92 6.36 59.28 7.67 .18

Note: CBCL = Child Behavior Checklist; YSR = Youth Self-Report.
*p < .05. **p < .01.

differences in any behavioral problems. Mothers of the respondents, however, identified girls in the ED groups as having more internalizing behavior problems, somatic complaints, and thought problems than the girls in the noED group.

Familial Predictors
The ED women and their mothers were significantly more likely to describe either a sibling or parent as having an eating problem that began before the respondent was 15 (Table 4). The parents of the ED women, compared with the noED women, were also significantly more likely to have a history of depression and drug problems with onset before the respondent was age 15.
There were also clear group difference in family life events and circumstances. At age 15, girls who developed eating disorders were significantly more likely than their peers to identify stressful family events that related to family financial status or parental employment changes. These included a change in parent financial status, a job change requiring father’s absence from home, and the loss of job by a parent. These changes appear to be unrelated to family socioeconomic status, which was not significantly different for the two groups at either age 9 or 15.

DISCUSSION

Few studies have followed a population of young women through important stages of their early development to young adulthood. The findings of this 22-year longitudinal study point to a number of factors across three major domains that predict the development of full or partial-syndrome eating disorders in a population of young women. First, our findings suggest hat early health problems are important predictors of the development of eating disorders. Specifically, compared with mothers whose daughters did not develop an eating disorders, mothers of girls with a history of an eating disorder were twice as likely to report pregnancy complications and to have girls who had more health problems as infants and toddlers. These results are consistent with a study in Sweden that found a significant relationship between perinatal factors and the later development of anorexia nervosa (Cnattingius et al., 1999). These findings suggest biologic contributions to eating disorders and highlight the need for more research to examine more fully the integration of biologic factors with behavioral and cultural factors (Steiger-Moore & Cachexia, 2001). Alternatively, it is possible that health problems during pregnancy and early childhood contribute to increased anxiety and perhaps even overprotectiveness on the part of mothers. Early childhood health problems also may promote sensitivity to physical and health issues on the part of the child that, in turn, might explain the levels of somatic complaints noted by mothers at age 15.
In parallel with findings from other studies (Fisher et al., 1991; Rierdan & Koff, 1997; Zaider et al., 2000), we found that anxious-depressed behavior was significantly relate to full or partial-syndrome eating disorders by young adulthood. Specifically, mothers of the ED group rated their daughters as exhibiting more anxious-depressed symptoms and behaviors at age 9 than girls in the noED group. It is noteworthy that the anxiety and depression reported by the mothers at age 9 preceded the development of the eating disorder. Therefore, mothers of the ED group were able to distinguish behavioral-emotional difference at age 9, before the onset of the disorder. At age 15, mothers reported that the girls who developed eating disorders had more behavior problems.

Table 4. Relationship between familial risks and eating disorders by age 27

Eating Disorder No Eating Disorder
(n = 21) (N - 47)
_---------------- -------------------------

Familial Risk % SE % SE x2

Familial history of eating
Problems by 15
Parent or sibling with eating
problems 57.1 11.1 31.9 6.9 3.86*

Parental history of disorder by 15
Parental depression 33.3 10.5 8.5 4.1 6.60***
Parental alcohol 47.6 11.2 27.7 6.6 2.58
Parental drug 19.0 8.8 2.1 2.1 6.10*

Familial financial change
Change in parent financial status 57.1 11.1 18.2 5.9 10.13***
Change in father’s job requiring
absence from home 19.0 8.8 2.2 2.2 5.94*
Loss of job by parent 28.6 10.1 6.5 3.7 6.03*
Low family socioeconomic status
at age 9 50.0 12.1 41.5 7.8 .54
Low family socioeconomic status
at age 15 33.3 10.5 45.7 7.4 .90

*p < .05. **p < .01. *** p < .001.

Because one third of the ED group reported onset of eating disorders before age 15, we cannot identify a temporal relationship between behavioral-emotional behaviors at age 15 and the development of eating disorders. These findings are best conceptualized as correlates of the disorders.
In contrast to the finding that at ages 9 and 15, mothers’ reports of behavioral-emotional symptoms were significantly different between the ED and the noED groups, there were no self-reported behavioral-emotional differences between the groups. On explanation for this finding is that it is indicative of the lack of interoceptive awareness, or the ability to recognize and accurately identify emotions or visceral sensations. This construct was first described by Bruch (1973) as being characteristic of anorexia nervosa and was later included as a subscale on the EDI (Garner, 1991). Keel, Klump, Leon and Fulkerson (1998) found a lack of interoceptive awareness to be associated with eating pathology in a population of adolescent boys. In the current study, at both ages 9 and 15, the girls who developed eating disorders reported few, if any, problems with whereas their mothers identified a number of difficulties, particularly in the internalizing realm. This discrepancy between mother and daughters may well be a product of that lack of introspective awareness. In other words, mothers could see that their daughters were troubled but the girls did not recognize or were unable to identify the feelings.
We found that family events also differentiated the two groups. At the age 15 assessment, significantly more girls from the ED group identified family events, occurring by the age of 15, that reflected change in their family’s financial status. This is apparently unrelated to socioeconomic status. Our study found no association between socioeconomic characteristics and eating disorders. It would be useful for future studies to explore the mechanisms underlying the relationship between economic stressors (such as a parent losing his/her job) and child’s risk for an eating disorder. It is possible that financial changes within the family are experienced as a threat to an adolescent’s sense of stability and self-esteem and may become a source of anxiety and stress.
The current study is limited by the small homogeneous (mostly White and working and lower middle-class) sample, which restricts the generalizability of the results and limits the statistical power of the analysis so that only fairly large differences are significant. Because eating disorders are relatively rare (Fairburn & Beglin, 1990;Garfinkel et al., 1995), very large samples are needed to identify an adequate number of cases within a community population.
However, these limitations are offset by several strengths. The most important aspect of this study is the span of time over which each respondent was interviewed. The early data, collected at ages 5 and 9, give a perspective that not only makes a significant contribution to the current knowledge base, but points to new directions for future research. Additional research should continue to investigate the findings of our study: pregnancy complications and early health problems, mother reports of behavioral and emotional difficulties, and changes in family finances in adolescence as predictors of eating disorders.

REFERENCES

Achenback, The., & Edelbrock, C. (1983). Manual for the Child Behavior Checklist and Revised Child Behavior Profile. Burlington: University of Vermont

Achenback, The., & Edelbrock, C. (1987). Manual for the Youth Self-Report and Profile. Burlington; University of Vermont

Allen, N.B., Lewinsohn, P.M., & Seeley, J.R. (1998). Prenatal and perinatial influences on risk for psychopathology in childhood and adolescence.
Development and Psychopathology, 10, 513-529
American Psychiatric Association. (1994). Diagnostic and statistical manual of mental disorders (4th ed.) Washington, D.C.; Author.

Attie, L, & Brooks-Gunn, J. (1989), Development of eating problems in adolescent girls; A longitudinal study. Developmental Psychology, 25, 70-79

Bruck, H (1973). Eating disorders. New York; Basic Books

Button, E.J., Sonuga-Barke, E.J.S., Davies J., & Thompson, M. (1996). A prospective study of self-esteem in the prediction of eating problems in
adolescent schoolgirls; Questionnaire findings. British Journal of Clinical Psychology, 35, 193-203
Cnattingius, S., Hultman, C.M., Dahl, M., & Sparen, P. (1999). Very preterm birth, birth trauma, and the risk of anorexia nervosa among girls. Archives of General Psychiatry, 56, 634-638.
Crago, M., Shisslak, C.M., & Ruble, A. (2001). Protective factors in the development of eating disorders. In R.H. Striegel-Moore & L.Smolak (Eds.), Eating disorders: Innovative directions in research and practice (pp. 75-89). Washington, D.C.: American Psychological Association.
Fairburn, C.G., & Beglin, S.J. (1990). Studies of the epidemiology of bulimia nervosa. American Journal of Psychiatry,
147, 401-408
Fisher, M., Schneider, M., Pegler, C., & Napolitano, B. (1991). Eating attitudes, health-risk behaviors, self-esteem, and anxiety among
Adolescent females in a suburban high school. Journal of Adolescent Health, 12, 377-384.
Garfinkel, P.E., Lin, E., Goering, P., Spegg, C., Goldbloom. D.S., Kennedy, S., Kaplan, A.S., & Woodside, D.B. (1995). Bulimia nervosa in a Canadian
community sample: Prevalence and comparison of subgroups. American Journal of Psychiatry, 152, 1052-1058.
Garner, D. (1991). Eating Disorders Inventory 2 professional manual. Odessa, Florida
Psychological Assessment Resources.
Hollingshead, A.G. (1971) . Commentary on "The indiscriminate state of social class measurement."
Social Forces, 49, 563-567.
Janca, A., Bucholz, K.K., & Janca, I. (1992). Family history assessment module.
Unpublished manuscript, Washington University, St., Louis, MO
Keel, P.K.., Fulkerson, J.A., & Leon, G.R., (1997). Disordered eating precursors in pre- and early
adolescent girls and boys. Journal of Youth and Adolescence, 26, 203-216.
Keel, P.K., Klump, J.L., Leon, G.R., & Fulkerson, J.A. (1998) Disordered eating in adolescent males in a school-based
sample. International Journal of Eating Disorders, 23, 125-132.
Killen, J.D., Taylor, C.B., Hayward, C., Haydel, F., Wilson, D.M., Hammer, L., Kraemer, H., Blair-Greiner, A., & Strachowski, D. (1996).
Weight concerns influence the development of eating disorder: A 4-year prospective study. Journal of Consulting and Clinical Psychology,
64, 936-940.
Klump, K.L., Kaye, W.H., & Strober, M. (2001). The evolving genetic foundations of eating disorders.
Psychiatric Clinics of North America, 24, 215-225.
Kraemer, H., Kazdin, A.E., Offord, D.R., Kessler, R.C., Jensen, P.S., & Kupfer, D.J. (1997)
Coming to terms with the terms of risk. Archives of General Psychiatry, 54, 337-343.
Lewinsohn, P.M., Striegel-Moore, R.H., & Seeley, J.R., (2000), Epidemiology and natural course of eating disorders in young women
From adolescence to young adulthood. Journal of the American Academy of Child and Adolescent Psychiatry, 39, 1284-1292.
Lilenfield, L.R., Kaye, W.H., Greeno, C.G., Merikangas, K.R., Plotnikov, K.., Pollica, C., Rao, R., Strober, M., Bulik, C.M., & Nagy, L. (1998)
A controlled family study of anorexia nervosa and bulimia nervosa: Psychiatric disorders in first degree relatives and effects of
proband comorbidity. Archives of General Psychiatry, 55, 603-610.
Piers, E.V. (1984). Piers-Harris children’s self-concept scale, revised manual.
Los Angeles: Western Psychological Services.
Pine, D.S., Cohen, , P., Brook, J., & Coplan, J.D. (1997). Psychiatric symptoms in adolescence as predictors of obesity
in early childhood: A longitudinal study of American Journal of Public Health, 87, 1303-1310.
Reinherz, H., & Gracey, C.A.. (1983). The Simmons Behavior Checklist: Technical information. Boston: Simmons College
School of Social Work.
Reinherz, H.Z., Giaconia, R.M., Carmola Haug, A.M., Wasserman, M.S., & Silverman, A.B. (1999). Major depression in the transition to adulthood:
Risks and impairments. Journal of Abnormal Psychology, 108, 500-510.
Rierdan, J., & Koff, E. (1997). Weight, weight-related aspects of body-image, and depression in early
adolescent girls. Adolescence, 32, 615-624.
Robins, L., Cottler, L.., Bucholz, K., & Compton, W. (1995). Diagnostic Interview Schedule for DSM-IV.
St. Louis, MO: Washington University.
Rosen, J.C., Compas, B.E., & Tacy, B. (1993), The relation among stress, psychological system, and eating disorder symptoms:
A prospective analysis. International Journal of Eating Disorders, 14 153-152.
Stice, E. (2001). Risk factors for eating pathology: Recent advances and future directions. In R.H. Striegel-Moore &
L. Smolak (Eds.), Eating disorders: Innovative directions in research and practice (pp. 51-73). Washington, DC: American Psychological Association
Vohs, K.D., Heatherton, T.F., & Herrin, M. (2001). Disordered eating and the transition to college:
A prospective study. Internation Journal of Eating Disorders, 29, 280-288.
Wiederman, M.W., & Pryor, T. (1996). Substance use among women with eating disorders. Internantional Journal of Eating Disorders
29, 280-288.
Zaider, T.I., Johnson, J.G., & Cockell, S.J. (2000) Psychiatric comorbidity associated with eating disorder symptomology among
adolescents in the community. International Journal of eating disorder, 28, 58-67.