Topic; Anorexia Nervosa and its biological, social and psychological factors. Paper must be 3-5 pages written in 7th edition APA format. Paper must include title page, abstract, main body, reference.

The quality of relationships with one ’s mother and father and ED symptoms The parent –child relationship of individuals with ED has been the focus of much theoretical and empirica l research (Leonidas & Dos Santos, 2014 ). Both positive (e.g. communicati on, trust, closeness) and negative (e.g. conflicts, detachm ent, blame) aspects of the quality of parental relationships have been shown to distinguish individuals with an ED from control groups (Humphrey, 1986 ; Latzer, Lavee, & Gal, 2009 ). For example, compared with non-ED subjects, women with an ED perceive lower levels of warmth, trust, and communication and higher levels of alienation (detachment, resentment, i solation) in their relationships with their parents (Calam, Waller, Slade, & Newton, 1990 ; Orzolek-Kronner, 2002 ). In contrast, other authors found that communication and trust in the relationship with one ’s mother, as well as alienation in the relation- ship with both parents, distinguishe dEDparticipantsfromnon-EDsub- jects, but no significant group differences emerged on measures of paternal communication and trust (Cunha, Relvas, & Soares, 2009 ). Existing comparative research t hus highlights the importance of EATING DISORDERS 389 examining mother – and father –adolescent relationships separately and supports the notion that individuals with an ED experience low-quality relationships with their parents. However, a related question that has received less attention is whether the perceived quality of interactions with one ’s mother and father is associated with the severity of symptoms in individuals with an ED. This line of inquiry is particularly important for the planning of comprehensive interventions, especially considering that symptom severity has been identified as a pre- dictor of outcomes and treatment response in ED (Vall & Wade, 2015 ) and that parents are increasingly involved in the treatment of these conditions (Le Grange, Lock, Loeb, & Nicholls, 2010 ). The quality of interactions with close others, mainly parents, may have a direct impact on symptom severity in individuals with an ED. Indeed, interactions that are perceived as being marked by conflicts, hostility, control, or overprotection are hypothesized to inadvertently reinforce pro-anorectic attitudes and behaviours, as the person with an ED entrenches his or herself further in the disorder as a way to avoid negative relationships (Schmidt & Treasure, 2006 ). To date, studies conducted with non-clinical samples have shown that parental rela- tionships characterized by poor communication (Al Sabbah et al., 2009 ), lower levels of closeness (Swarr & Richards, 1996 ), and higher levels of conflicts (Hanna & Bond, 2006 ) are associated with higher levels of eating pathology. Research examining these associations in clinical samples is more limited and shows variations when interactions with mothers and fathers are considered separately (Horesh, Sommerfeld, Wolf, Zubery, & Zalsman, 2015 ; Rothschild-Yakar, Levy-Shiff, Fridman-Balaban, Gur, & Stein, 2010 ). More research is thus required to elucidate the nature of these associations in clinical samples of adolescents.

The quality of relationships with one ’s peers and ED symptoms While parents remain important relationships for the majority of youth, interactions with peers come to play a unique role in adolescents ’adjustment and largely contribute to their self-concept and well-being (Nickerson & Nagle, 2005 ). Some authors have suggested that the quality of peer relation- ships may be more influential than parental interactions in domains that gain significance during this period, such as self-image (O ’Koon, 1997 ). Despite these findings, the peer relationships of youth suffering from an ED have been somewhat neglected in the literature (Leonidas & Dos Santos, 2014 ). According to theoretical models, interpersonal difficulties with peers might directly contribute to ED symptom severity. For instance, it has been hypothesized that patients with an ED who experience negative interactions with their friends might come to be more isolated from the normalizing influence of the peer group, which could lead to a greater endorsement of 390 J. PELLETIER BROCHU ET AL. problematic eating attitudes and behaviours (Murphy, Straebler, Basden, Cooper, & Fairburn, 2012 ). Qualitative studies suggest that individuals with an ED generally report difficulties in establishing and maintaining positive friendships and tend to feel disconnected from their peers (Westwood, Lawrence, Fleming, & Tchanturia, 2016 ). However, few quantitative studies have explored the link between the quality of relationships with friends and ED symptoms. In non-ED adolescents, disordered eating symptoms have generally been associated with negative aspects of friendships (i.e. alienation and conflicts; French, Story, Downes, Resnick, & Blum, 1995 ; Schutz & Paxton, 2007 ), but not positive aspects (i.e. social support, intimacy; Gerner & Wilson, 2005 ; Schutz & Paxton, 2007 ). To the best of our knowledge, no studies have examined the link between the quality of peer relationships and symptom severity in adolescents diagnosed with an ED. Given the significance of friendships during adolescence, the quality of peer relationships in relation to ED symptom severity needs to be investi- gated in youth with these conditions, as this might be a significant aspect to consider in planning interventions aimed at this population. Moreover, further elucidation of how different relationships that are central during adolescence can contribute to the severity of an ED is necessary in order to clarify their role in the maintenance of these disorders and to identify potential underlying mechanisms to target in treatment (Gander, Sevecke, & Buchheim, 2015 ). Psychological factors: low self-esteem and negative mood More recently, researchers and theorists have argued for the importance of examining potential mediating factors that could explain the link between poor-quality relationships and ED (Champion & Power, 2012 ; Rieger et al., 2010 ). The utility of identifying the mechanisms underlying this association is supported by the body of evidence demonstrating the efficacy of interven- tions focusing on interpersonal problems in the treatment of ED (Champion & Power, 2012 ). Of the factors that have been postulated as potential mediators, LSE and negative mood appear particularly relevant for adoles- cents with an ED (Rieger et al., 2010 ). LSE is considered one of the prominent psychological factors implicated in the onset and maintenance of ED pathology (Stice, 2002 ). According to some theore- tical perspectives, self-esteem is essent ially an internal monitor of the degree to which an individual is valued/accepted or devalued/rejected by others (Leary & Baumeister, 2000 ). In line with this notion, within the ED literature, it has been hypothesized that negative interpersonal relationships with significant others may lead to a diminished sense of self-esteem which, in turn, contributes to increased efforts to achieve in socially valued domains, such as weight and shape control, as a means to increase self-worth (Fairburn et al., 2003 ;Riegeretal., 2010 ). Such EATING DISORDERS 391 conceptualisations have received preliminary support in community samples of adults, where LSE was shown to mediate the association between interpersonal problems and over-evaluation of weight and shape, but not dietary restraint (Lampard et al., 2011 ). Empirical research testing this model in clinical samples of adolescents is lacking (Macek & Jezek, 2007 ;Sadovnikova, 2016 ). In adolescent females with Anorexia Nervosa (AN), LSE has been associated with poor social relationships (Iniewicz, 2004 ). On the other hand, some authors have documented associations between LSE and disorde red eating symptom severity (Button, Sonuga-Barke, Davies, & Thompson, 1996 ;Wilksch&Wade, 2004 ). Patients with an ED also generally report lower self-esteem levels than normal controls (Ghaderi & Scott, 2001 ). Thus, the findings that LSE is related to interpersonal difficulties and ED symptoms, as well as the theoretical models postulating a link between these variables, suggest that it might be useful to examine LSE as a mediator of the association between poor-quality relationships and ED symptom severity in adolescent patients. Another psychological factor that has been proposed as a mediator in the association between interpersonal relationships and ED symptoms is negative mood (Rieger et al., 2010 ). Theoretically, it has been suggested that increased efforts at controlling weight and shape serve as a means to numb or avoid negative emotions that might result from low-quality interpersonal relationships (Schmidt & Treasure, 2006 ;Slade, 1982 ). This model has been supported in adult women presenting different subtypes of ED, but no studies have validated this conceptualisation in clinical samples of adolescents with an ED (Ivanova et al., 2015 ). Although few studies have examined the quality of interpersonal relationships, negative mood and ED symptoms conjointly in adolescent, there is an important body of literature associating negative emotions to low-quality interac- tions (Armsden & Greenberg, 1987 ;LaGreca&Harrison, 2005 )andto eating pathology separately (Espeset, Gulliksen, Nordbo, Skarderud, & Holte, 2012 ). Longitudinal studies have documented that higher levels of negative aspects of relationships wi th parents and peers, such as rejec- tion and conflicts, are linked to greater levels of depressive symptoms in adolescents over time (Nolan, Flynn, & Garber, 2003 ; Stice, Ragan, & Randall, 2004 ), although this association is likely bidirectional (Kochel, Ladd, & Rudolph, 2012 ). Experimental research conducted with clinical samples has also established that increases in negative mood lead to increases in self-report ED symp toms (Wildes, Marcus, Bright, & Dapelo, 2012 ). In addition, certain studies have failed to find significant associations between relationship quality and eating pathology after accounting for co-occurring depressi ve symptoms, which highlights the need to further examine the interconnections between these variables (Schutz & Paxton, 2007 ). 392 J. PELLETIER BROCHU ET AL. Current study The aim of the present study is to clarify the links among the quality of multiple interpersonal relationships, self-esteem, negative mood, and ED symptoms in a clinical sample of adolescent females. Specifically, this study seeks to determine whether adolescents ’perception of specific positive (trust, communication) and negative (alienation) aspects of their relationships with their mother, father and peers are associated with ED symptom severity at the time of diagnosis. A second objective is to test the mediating effects of LSE and negative mood on these associations. Based on the previous litera- ture, it is hypothesized that adolescents ’perception of lower relationship quality with their mother, father, and peers will individually be associated with more severe ED symptoms. Given the paucity of research on the topic, no hypotheses were made regarding the respective contributions of specific positive and negative dimensions with one ’s interpersonal relationships on ED symptoms severity. Finally, it was anticipated that LSE and negative mood would both act as mediators in the associations between perceived poor quality of the relationship with one ’s mother, father, and peers and ED symptom severity.

Methods Participants and procedures The sample is composed of 186 adolescent females who were recruited through specialized ED programs for adolescents in three University Health Centers across the province of Quebec. Data were collected as part of a larger study examining personal, social, and familial functioning in youth admitted to inpatient programs or receiving outpatient treatment for an ED. For the present study, adolescent females between the ages of 12 and 18 ( M = 15.36 years, SD = 1.38) who met the Diagnostic and Statistical Manual of Mental Disorders (DSM-IV-TR; American Psychiatric Association, 2000 ) criteria for the Restrictive (AN-R; N = 171, 91.90%) or Binge/Purge subtypes of Anorexia Nervosa (AN-BP; N = 15, 8.10%) were selected from the total sample. At the time of completion, subjects had received a diagnosis of AN for a mean time of 2.99 months (SD = 7.23). The Research Ethics Committee of each of recruitment site approved the project and recruitment procedures were similar across Health Centers. As part of the treatment protocol in the three Health Centers, children and adolescents receiving a diagnosis of AN for the first time were asked to complete self-report questionnaires pertaining to their eating habits and their personal, social, and familial functioning. Once the questionnaires were completed, participants were asked whether they agreed to have their data used in the context of a longitudinal research project and to be EATING DISORDERS 393 contacted 1 year later to complete further questionnaires. Informed parental consent and adolescent assent were obtained for those who accepted to join the study.

Measures Demographics and diagnostic information Socio-demographic information was given by the medical team from each recruitment site. Diagnoses were established by medical professionals trained and experienced in ED.

Eating disorder inventory ED symptomatology was assessed using the Eating Disorder Inventory (EDI-3) (Garner, 2004 ), a widely used self-report questionnaire that measures ED symptoms (three scales) and psychological traits (nine scales) relevant to AN, Bulimia Nervosa (BN), and Eating Disorder Not Otherwise Specified (EDNOS).

The EDI-3 consists of 91 items that are scored using a 6-point Likert scale. After reverse-scoring the negatively keyed items, total raw scores for each scale are obtained by adding the relevant items and are then transformed into T scores (Garner, 2004 ). Six second-order composites can be generated from the scales. In the present study, the Eating Disorder Risk Composite (EDRC), which is comprised of the summed T scores on the Drive for Thinness (DT), BN, and Body Dissatisfaction (BD) scales, was used as an index of ED symptom severity.

EDRC scores were adjusted for age and diagnosis (Garner, 2004 ). The LSE subscale was also used to evaluate participants ’level of self-worth. The values of Cronbach ’sαfor the various scales were between .85 and .92. Inventory of attachment to parents and peers The perceived quality of one ’s relationship with parents and peers was measured using the IPPA (Armsden & Greenberg, 1987 ,1989 ). This self- report questionnaire assesses adolescents ’perceptions of positive and nega- tive affective/cognitive dimensions of their relationships. The revised version of the IPPA used in the present study is comprised of 28 items in each parent section (i.e. mother and father) and 25 items in the peer section (Armsden & Greenberg, 1989 ). Items are rated on a 5-point Likert scale. For each section, two positive (Trust and Communication) and one negative (Alienation) dimensions of relationship quality are assessed: trust items assess the degree of mutual understanding and respect, communication items assess the extent of spoken communication, and alienation items tap into feelings of detach- ment, isolation, and resentment. In the present study, total scores were calculated for each of the subscales (Trust, Communication, Alienation) in the three sections of the inventory (Mother, Father, Peers), after reverse- scoring the negatively worded items. The Inventory of attachment to parents 394 J. PELLETIER BROCHU ET AL. and peers (IPPA) has been successfully used in several studies and has good psychometric properties (Armsden, McCauley, Greenberg, Burke, & Mitchell, 1990 ). The values of Cronbach ’sαof the subscales ranged between .79 and .94 in the present study.

Beck depression inventory Negative mood (i.e. depressive symptoms) was assessed using the Beck Depression Inventory (BDI-II) (Beck, Steer, & Brown, 1996 ), a self-report questionnaire consisting of 21 groups of four statements. For each group of statements, respondents are asked to select the one that best applies to their situation over the past 2 weeks. Statements correspond to a severity rating from 0 (minimal) to 3 (severe). Responses to each statement are then summed up and a total score indicating the levels of depressive symptoms is obtained. The BDI-II is commonly used to measure negative mood in adolescents and has been shown to have excellent psychometric properties (Beck et al., 1996 ). Research has also shown that it is a valid measure of negative mood in patients with an ED (Pulos, 1996 ). The Cronbach ’sα for this measure was .93.

Results Correlations analyses and multiple regressions Before testing the study ’s hypotheses, zero-order correlations were calculated and are reported in Table 1 . Correlations among all variables were significant at the .01 level. In order to meet the first objective of the study, multiple regressions were conducted using EDRC score as the dependent variable and each of the subscales of the IPPA as predictors. Prior to the analyses, the relevant assumptions of multiple regressions were tested and all were satis- fied. As shown in Table 2 , the overall model including all relationship quality measures explained a significant amount of the variance in ED symptom severity [ F(9, 158) = 9.57, p < .01, R2= .37]. An examination of the beta weights for each individual predictor indicated that only perceived alienation in the relationships with one ’s mother ( β= .32, p< .05) and peers ( β= .27, p< .01) made a significant contribution to ED symptom severity. Specifically, higher scores on the mother and peer alienation subscales separately pre- dicted higher levels of ED symptom intensity, when all the other variables were included. As the only significant predictors of the severity of ED pathology were perceived mother and peer alienation, after accounting for all other independent variables, only these two variables were retained as separate predictors in subsequent mediation analyses. EATING DISORDERS 395 Table 1.

Intercorrelations among ED symptom severity, relationship quality variables and psychological factors. Variables 123456789101112 ED Sx severity _ Mother comm.

.35** _ Mother trust .38** .84** _ Mother alien. .47** .78** .83** _ Father comm.

.31** .56** .52** .54** _ Father trust .39** .55** .61** .61** .82** _ Father alien. .43** .46** .46** .59** .76** .84** _ Peers comm.

.33** .31** .31** .31** .24** .31** .29** _ Peers trust .38** .36** .38** .39** .23** .36** .35** .86** _ Peers alien.

.50** .37** .40** .52** .33** .40** .47** .63** .66** _ Low self-esteem .69** .36** .40** .48** .29** .34** .41** .38** .44** .62** _ Negative mood .65** .38** .40** .50** .32** .40** .44** .36** .46** .65** .75** _ Note .** p< 0.001. Sx = Symptom; Comm. = Communication; Alien. = Alienation. 396 J. PELLETIER BROCHU ET AL. Mediation analyses In order to simultaneously assess the effects of LSE and negative mood on the links between perceived maternal/peer alienation and ED symptom severity, two separate mediation models, each including one of the predictors and the two proposed mediators, were examined. The mediation effects were ana- lysed using PROCESS in SPSS. Bootstrapping sampling procedures were applied, as recommended by Preacher and Hayes ( 2008 ). In the current study, 1000 replications were used and 95% confidence intervals were con- sidered significant if they do not encapsulate zero. Finally, to facilitate the interpretations of the results, all variables were standardized before being included in the mediation analyses. Results for each of the two mediation analyses are presented graphically in Figure 1 and Figure 2 . LSE ( b= .21, BCa CI [0.14, 0.31]) and negative mood (b = .14, BCa CI [0.06, 0.23]) partially mediated the association between alienation in the relationship with one ’s mother and ED symptom severity. The effect of perceived alienation from one ’s mother on ED symptom severity, although small, remained significant in the global mediation model ( b = .13, p < .05), which accounted for 53.25% of the variance in symptom severity. There was also a significant indirect effect of perceived alienation in peer relationships on ED symptom severity through LSE (b = .27, BCa CI [0.18, 0.38]) and negative mood ( b = .19, BCa CI [0.09, 0.32]). The effect of perceived alienation from one ’s peers on ED symptom severity was not significant when the mediating variables were accounted for (b=.04, p= .59). The global model with peer alienation as the independent variable accounted for 51.30% of the variance in symptom severity.

Discussion The present study revealed that levels of perceived alienation, but not com- munication and trust, in the relationship with one ’s mother and peers were Table 2. Multiple regressions for relationship quality variables predicting ED symptom severity. Predictor variables B SE B β Mother comm. .03 .17 .02 Mother trust .04 .20 .03 Mother alien. .46 .21 .32* Father comm. .11 .15 .09 Father trust .11 .20 .09 Father alien. .13 .22 .09 Peers comm. .01 .21 .01 Peers trust .10 .16 .09 Peers alien. .64 .24 .27** R2 .37 F 9.57** Note. * p< .05; ** p< .01. Comm. = Communication; Alien. = Alienation. EATING DISORDERS 397 positively associated with ED symptom severity in a sample of adolescents with AN. In contrast, neither the positive nor the negative aspects of the relationship with one ’s father were significantly associated with the severity of ED pathology. In addition, it was found that LSE and negative affect act as mediators in the association between the severity of ED symptoms and the level of perceived alienation in the relationship with both one ’s mother and peers. The current findings add to the body of literature, suggesting that a link between perceived a low-quality maternal relationship and the presence of ED symptoms (Hanna & Bond, 2006 ; Rothschild-Yakar et al., 2010 ). More precisely, adolescents with an ED who perceive more detachment and resent- ment in the interactions with their mother also endorsed more severe ED pathology, even after accounting for the quality of relationships with their father and peers. This is consistent with past findings of significant positive associations between ED symptom severity and both a lack of closeness Figure 2. Standardized regression coefficients for the association between alienation in the relationships with peers and ED symptom severity as mediated by low self-esteem and negative mood.

Figure 1. Standardized regression coefficients for the association between alienation in the relationships with mother and ED symptom severity as mediated by low self-esteem and negative mood.

398 J. PELLETIER BROCHU ET AL. (Swarr & Richards, 1996 ) and higher conflicts (Hanna & Bond, 2006 ) in the adolescent –mother relationship. These results are interesting to interpret in the light of recent evidence showing that mothers of adolescents with an ED, who are usually the primary caregivers, often adopt emotionally driven behaviours (e.g. criticisms, overinvolvement, control) as a result of the burden and high levels of distress that they experience (Rhind et al., 2016 ). It is possible that such attitudes and behaviours contribute to the feelings of alienation experienced by adolescents in the context of the relationship with their mother, which in turn exacerbate ED symptoms (Fairburn et al., 2003 ; Schmidt & Treasure, 2006 ). On the other hand, the design of the present study does not allow causal interpretations and the association is most likely bidirectional. Indeed, ED symptom severity may influence how close others react to the individual with the diagnosis, and thus the perceived quality of interpersonal relationships (Schmidt & Treasure, 2006 ). Contrary to our expectations, positive and negative aspects of the relationship with one ’s father were not significantly associated with ED symptom severity, when mother and peer relationships variables were considered. Associations between the negative attributes of father –child relationships and ED severity have been documented in previous research (Horesh et al., 2015 ), although studies controlling for other types of relationships have offered mixed findings (Rothschild-Yakar et al., 2010 ). Several hypotheses can be advanced to explain the results reported in the current study. First, the sample was composed exclusively of females. It is possible that the quality of the relationship with the same-sex parent is more influential during the adolescent period, a finding that is supported in the developmental literature (Paterson, Field, & Pryor, 1994 ). In addition, the quality of the relationship with one ’s father might not be associated with ED severity, but with other factors that could potentially contribute to the maintenance of an ED. For instance, in one study, the quality of the paternal relationship, but not of the maternal relationship, was predictive of motivation to recover in individuals exhibiting ED characteristics (Warshawsky & Handelzalts, 2014 ). Thus, from a clinical perspective, the results of the present study suggest that, at the beginning of treatment, youth with an ED might beneficiate from interventions focusing on improving the relationships with their mother and peers, as this might be associated with reduced symptom severity. As treatment progresses, the quality of the paternal relationship might become an important target of intervention in order to help enhance aspects likely to facilitate the recovery process, such as motivation. The cross- sectional design of the current study only allows for speculations regarding temporal effects and further longitudinal research is needed to clarify the contribution of the father –child relationship to ED symptom severity. Nonetheless, the results underscore the importance of examining different types of relationships separately, as they may not contribute equally to ED symptom severity in adolescents. EATING DISORDERS 399 It is noteworthy that perceived alienation in peer interactions was a significant predictor of ED symptom severity in the present study, even when the quality of parental relationships was considered. The present investigation provides further support for the association between negative aspects of peer interactions and the intensity of ED symptoms documented in other research (Schutz & Paxton, 2007 ) and underscores the importance of considering relationships outside of the family in the evaluation and treat- ment of adolescents with an ED. As suggested by some authors, patients with an ED who experience conflicts and alienation in their relationships with friends may come to be more isolated, which might lead to a greater endorsement of problematic eating attitudes and behaviours (Murphy et al., 2012 ). On the other hand, past research has also suggested that increasingly rigid eating attitudes and behaviours may interfere with girls ’capacity to sustain positive friendships (Schutz & Paxton, 2007 ) and exacerbate social isolation (Shelley, 1997 ). Given the cross-sectional design of the study, it is not possible to draw conclusions regarding the direction of the effect and prospective studies examining how the quality of peer interactions is asso- ciated with ED symptoms over time are warranted. Another central contribution of the present study is the examination of LSE and negative mood as mechanisms accounting for the associations between perceived alienation from one ’s mother and peers and the severity of ED symptoms. Several theories have postulated that interpersonal pro- blems contribute to the maintenance of ED via their detrimental effects on self-esteem and mood (Fairburn et al., 2003 ; Rieger et al., 2010 ). However, empirical evidence testing these theories is limited, especially in clinical samples of youth (Ivanova et al., 2015 ; Lampard et al., 2011 ). The present study provides preliminary support for the applicability of these conceptua- lisations to adolescents females with AN. The quality of social interactions with others, particularly with family and friends, largely influences adolescents ’sense of self (Laible, Carlo, & Roesch, 2004 ) and their personal and emotional adjustment (Boutelle, Eisenberg, Gregory, & Neumark-Sztainer, 2009 ; La Greca & Harrison, 2005 ). As results from the current study suggest, negative relationships may undermine self- esteem and lead to increased efforts at controlling eating and weight as a mean to gain a sense of control in patients with AN (Bruch, 1973 ). In addition, perceiving hostility and resentment in the relationships with one ’s mother and peers might contribute to heightened levels of negative mood, as youths are less likely to share personal experiences and receive needed validation when they hold the belief that interacting with others will result in negative outcomes (Geller, Cockell, Hewitt, Goldner, & Flett, 2000 ). Evidence also suggests that individuals with an ED generally present a lack of interoceptive awareness and difficulties in effectively managing emotional experiences, thereby making them more prone to rely on inappropriate 400 J. PELLETIER BROCHU ET AL. coping strategies (Ruscitti, Rufino, Goodwin, & Wagner, 2016 ). Thus, the current results support the idea that, in some adolescents, engaging in increasingly severe AN behaviours may come to replace healthy engagement with the social world as a way to attain positive self-worth and cope with negative affect (Rieger et al., 2010 ). Although interpretations of the results are limited by the cross-sectional design of the study, it can be hypothesized that these models are likely to be self-perpetuating. Theoretical conceptualisations suggest that interpersonal difficulties might contribute to LSE, negative affect, and ED symptoms, which maintain one another and eventually exacerbate problems in one ’s relationships with others (Fairburn et al., 2003 ; Rieger et al., 2010 ). Other authors have also postulated that ED symptoms may lead relatives to react towards the person with an ED in ways that inadvertently reinforce beliefs of self-efficacy or feelings of reassurance, which in turn exacerbate pro-anorectic beliefs and behaviours (Schmidt & Treasure, 2006 ). Overall, this study adds to the bod y of literature on interpersonal relationships and ED by expanding upon the results of previous studies in several ways. First, the sample is composed exclusively of female adolescents with AN and is considerably larger than samples used in previous research on this population. Second, the present study examined various types of interpersonal relationships believed to be central in adolescence, many of which have been fairly neglected in the ED litera- ture. Indeed, most of the research on attachment and ED has focused on the mother –daughter relationship, and few studies have examined the quality of the relationship with one ’s father and peers (Leonidas & Dos Santos, 2014 ). Another central contribution of the current investigation is the identification of psychological variables acting as mediators of the association between the perceived quality of maternal and peer relation- ships and ED symptom severity. Increasingly, theorists and researchers have argued for the importance of integrating multiple social and personal factors in trying to explain the aetiology and maintenance of ED pathol- ogy (Fairburn et al., 2003 ;Riegeretal., 2010 ). Despite important contributions, the current study also has its limita- tions. First, the sample is composed exclusively of females, which limits the possibility of generalizing the r esults to adolescent males. Future studies should examine potential gen der differences in the associations between perceived relationship quality and ED symptom severity, as it has been shown in community samples that boys are more likely than girls to rely on their father for support (Colarossi, 2001 ). Moreover, conclusions of the present study ar e particularly relevant for AN and might not be generalizable to other diagnostic subtypes. It is also importanttonotethatparticipants ’ethnicity was not documented in the present study. This variable should be taken into consideration in future research. Another limitation of the present study is the reliance EATING DISORDERS 401 on self-report measures. Individuals with an ED, in part as a conse- quence of starvation, tend to have impairments in socio-emotional processing and to show an automatic bias in attention towards critical faces and away from compassionate faces (Treasure & Schmidt, 2013 ), which might have resulted in them over estimating conflicts and aliena- tion in their relationships. Therefo re, future research would benefit from the use of multiple informants ’reports (mother, father, peers) or alternative measures of the quality o f interpersonal relationships (e.g. observations in an experimental de sign). Replication of the present study using more objective measures of ED severity (e.g. ratings by trained clinicians) is also warranted. Finally, the cross-sectional nature of the present study makes it impossible to confidently determine directionality and causality of results. Experimental and longitudinal studies are needed to explore how adolescents ’perceptions of their relationships with their mother, father, and peers evolve over time and how this evolution is related to changes in ED symptomatology.

Prospective pre –post studies would be valuable in identifying the ways in which the perceived quality of inte rpersonal interactions changes in relationship to the diminution of ED severity as a result of treatment.

Conclusion The main implication of the present study is to provide preliminary support for clinically informed models, suggesting that interpersonal problems are associated with ED symptom severity via their detrimental effects on self- esteem and affect (Fairburn et al., 2003 ; Rieger et al., 2010 ). The findings also highlight the differential associations between the perceived quality of multi- ple types of relationships (i.e. mother, father, and peer relationships), as well as different aspects within these interactions (i.e. communication, trust, alienation), and ED symptom severity. Considering that high levels of per- ceived alienation in the relationship with one ’s mother and friends appear to be associated with more severe ED symptoms through their impact on self- esteem and mood, improvements of the quality of these interactions are likely to be an effective target of interventions for adolescents. The results of the current study suggest that treatments focusing on specific relationship difficulties (e.g. communication, conflict resolution) and that help adoles- cents regain a sense of efficacy and experience positive affect in their familial and social interactions are important. In addition, given the crucial role of friendships during adolescence, the inclusion of the peer group, in addition to the family, as partners in the prevention and treatment of ED should be considered in the elaboration of effective interventions.

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