Parental feeding practices and the relationship with parents in female adolescents and young adults with eating disorders: A case control study.

OBJECTIVE: Perceived parental influence on diet in early adolescence in the context of the parental relationship had previously not been studied in a clinical sample. The aim of this study was to investigate a possible association between eating disorders and characteristics of the relationship with parents and the parental feeding practices in early adolescence.
METHODS: 21 female adolescents and young adults with an eating disorder (ED)-bulimia nervosa or anorexia nervosa-and 22 females without eating disorder (healthy control; HC), aged between 16 and 26, were assessed via self-report questionnaires for problematic eating behaviour, relationship with parents, perceptions of parent's feeding practices at the age of 10-13 years and personality. Statistical evaluation was performed by means of group comparisons, effect sizes, regression analyses and mediator analyses.
RESULTS: Adolescent and young adult females with ED reported more fears/overprotection and rejection/neglect by their mothers and less self-responsibility in terms of eating behaviour during adolescence than did the HC. The relationship with the fathers did not differ significantly. Females who perceived more cohesion, rejection/neglect and fears/overprotection by the mother were more likely to suffer from an ED. Rejection/neglect by both parents were associated with less self-acceptance of the young females with even stronger effect sizes for the fathers than the mothers. Harm prevention in the young females was a partial mediator between fears/overprotection and the drive for thinness.
CONCLUSIONS: The parental relationship is partly reflected in the self-acceptance and self-responsibility in eating of the adolescent and young females, both of them are particularly affected in EDs. Stressors in the parent-child relationship should be targeted in treatment of eating disorders. Nutritional counselling for parents might be useful in early adolescence.

Introduction

Feeding and eating disorders (ED) are characterized by disturbances of eating and other behaviour, leading to changes in food consumption and impairing physical health or psychosocial functioning: Anorexia nervosa (AN) is defined by restrictions in energy intake in relation to need, resulting in significantly low weight. Bulimia nervosa (BN) describes recurring episodes of binge eating and inappropriate compensatory behaviour to prevent weight gain. In both disorders, self-evaluation is affected and strongly influenced by the way one experiences one’s body shape and weight [1].

ED mainly affect females and exhibit a significant increase of incidence during adolescence [2]. Lifetime prevalence of AN and BN for females is reported to be 2.9% (0.1% among males of the same age brackets) [3]. A longitudinal cohort study on children, adolescents and young adults in Germany [4] found that 21.9% of the 11 to 17 years old even showed symptoms of an ED. Furthermore, the rates of incidence as well as prevalence of AN among adolescents have been increasing significantly in recent years [5] particularly in the highly vulnerable period before or at the beginning of adolescence [6]. Pubertal development, with its physical changes, often precedes or accompanies adolescence and early maturing girls are reported to be at special risk from disordered eating [7]. Adolescence involves several major developmental tasks such as adapting to physical changes, creating one's own identity, defining goals for the future or learning self-regulation of emotions which present stressful situations for young girls [2].

The bio-psycho-social model for the development of psychiatric disorders [8], representing the theoretical background of this study, postulates, that the genetic vulnerability for developing a certain psychiatric disorder, together with the intrapersonal stress and the environmental stress factors (family, friends, schooling situation), may lead to the outbreak of a disease.

Since adolescence represents a period of the life cycle characterised by progressive independence from parents and family members, it may be particularly valuable to examine the extent to which family factors influence the behavioural and emotional wellbeing of the adolescents and consequently to the risk of developing an ED [2]. Subjectively perceived stressors in the parental relationship are hypothesized to increase the risk for psychosocial maladaptation and the occurrence of EDs [9]. Furthermore, the development of abilities to regulate emotions and impulses is influenced by the parental relationship [10] and the capacity to self-regulate was shown to be negatively affected by stronger parental control [11].

Attachment theory provides a comprehensive framework for understanding the psychological factors and family characteristics contributing to individual development in adolescence [12]. Early interactions and experiences with parents are internalized and used to regulate self-esteem. According to the attachment theory, secure attachment with availability, understanding and responsiveness of caregivers leads to a healthy self-esteem, while negative or inconsistent parenting behaviour is more likely to lead to problems in self-assessment [12].

The relationship between children and their parents instinctively shows different forms of bidirectional communications in different contexts and aims. Especially the feeding situation seems to play an important role in child-parent attachment. It has been shown that during feeding, when the relationship between children and parents is not able to coordinate and share sensitive interactions, the infant will not be able to learn the self-regulation of affects and may show maladaptive emotional and behavioural symptoms over time [13]. These parenting practices and their influence on children's emotional as well as food self-regulation abilities [14] are believed to play an important role in the development and maintenance of EDs [10, 14].

Parental overprotection during childhood is thought to lead to increased awareness of stress and mental health problems in adulthood [15]. Both, fathers and mothers of persons with EDs, are reported to overprotect their children [16]. However, while females with AN more frequently than their healthy siblings reported to have experienced maternal overprotection in their childhood, no such difference was reported for females with BN [17]. Contradictory, parents of patients suffering of AN [18-20] or BN [19] are postulated to be perceived as less caring, highly disengaged, poorly interwoven, rigid and with less cohesion and communication qualities, in comparison to parents of the respective peer group. It was also previously demonstrated, that persons with EDs experienced strong entanglement within their families [21]. To better understand parental impact on adolescents’ eating disorders, it is necessary to address the influence of parental feeding practices on eating behaviour. The current study addresses the limitations in the existing literature in several ways: Female patients with eating disorders (ED) and healthy controls (HC) were asked for both, their recent relationship with their parents and for their memories of parental feeding practices at early adolescence, retrospectively.

The first aim was to examine female adolescent and young adults with ED as well as the HC group for their contemporary perception of the relationships with their mother or father. Dysfunctional relationships with parents in females with ED are reported in literature, but previous data are contradictory. We expected the adolescent and young females with ED to report a significantly worse relationship with their mother or father than the HC.

The second aim was to explore a possible mediating role of the personality traits (“self-directedness”, “self-acceptance” and “harm avoidance”) on the maternal relationship and symptoms of eating disorders (“drive for thinness” and “body dissatisfaction”). Recent findings suggest self-regulating skills, such as self-compassion, reduce the effects of perfectionism on the development of ED [22]. Therefore, in the present study we anticipated a possible positive influence of personality traits on maternal relationship and eating disorder symptoms.

The third aim was to retrospectively evaluate the perceived parental influence on eating behaviour at the age of 10–13 years. Previous studies investigating the connection between the influence of parents’ feeding practices and anorexic or bulimic EDs have primarily focused on early childhood and are still under-represented in research [23]. To the best of our knowledge, no previous study exists investigating the perceived parental’ feeding practices in early adolescence in the context of the parental relationship in a clinical sample of females diagnosed with ED. However, controlling food-related parenting practices were associated with adolescent disordered eating behaviours in population-based samples [24], and restrictive parental feeding practices were shown to lead to disordered eating behaviour in children in longitudinal studies [25, 26]. We expected remembered parental feeding practices in terms of “feeding responsibility”, “monitoring”, “pressure to eat” and “restriction” to be significantly more frequent in females with EDs than in HC.

Methods

Subjects and procedures

Study design

This quantitative cross-sectional study aimed at examining the current situation and memories of the early adolescence in female adolescents and young adults with and without eating disorders (ED) using questionnaires. The data was collected in the period from September 2016 to February 2017. Although no longitudinally collected data was available, cause-effect conclusions could be drawn by using a structural modelling strategy [27].

Ethics and consent to participate

This study was approved by the ethics committee of the Medical University of Vienna (reference number: 1691/2016). Written consent by the participants, after thorough information about the study, was acquired in advance in all cases. Adolescents between 14 and 18 years of age are of legal age of consent in Austria. Thus, young females’ consent in our study population of older than 16 years, was sufficient–and in accordance with the Ethics Committee–and parents did not have to be informed about participation in the study.

Study setting

Female adolescents and young adults with ED were recruited from inpatient and outpatient care of the Clinical Division of Social Psychiatry at the Department for Psychiatry and Psychotherapy, and of the Department for Child and Adolescent Psychiatry of the Medical University of Vienna. The healthy control group (HC) was recruited via circle of acquaintances.

Study sample

Female adolescents and young adults with eating disorder. Females with an eating disorder (ED) were included if they a) were between 16 and 26 years of age b) were diagnosed with either the ICD-10 diagnosis bulimia nervosa (BN) (ICD-10: F50.2) or anorexia nervosa (AN) (ICD-10: F50.00)—restrictive type or AN—bulimic type (ICD-10: F50.01). The diagnoses were established by experienced clinicians at the recruitment institutions.

Healthy controls. Inclusion criteria for the healthy control group (HC) were a) the willingness to participate and b) sufficient German language skills. Exclusion criteria for the HC were a) the existence of a current or past diagnosis of an ED, b) values above the normal range in at least two of the three scales: “drive for thinness”, “bulimia”, “body dissatisfaction” of the Eating Disorder Inventory-2 (EDI-2) [28]. When recruiting the control group, a similar age distribution as in the group of females with eating disorders was aimed at, but no age matching was performed in the analysis.

Measurements

Demographic data of the participants were collected by means of a study specific questionnaire. Data about age, weight, diagnosed mental health disorders according to ICD-10 [29], participation and duration of psychological/psychiatric treatment, housing situation with/without parents and school degree were collected. The symptoms of EDs were investigated using the frequently used Eating Disorder Inventory 2 (EDI-2; German Version) [28]. The EDI-2 is a revision of the EDI-1 [30], in which three subscales have been added. In the original English version of the EDI-2, the internal consistencies (Cronbach's Alphas) for the eight original scales ranged from 0.80 to 0.91, of which three were used in this study and a Principal Component Analysis supported the factor structure of the original EDI, but not that of the three additional scales [31] not used in this study. For our study, the validated German version of the questionnaire was used, which contains 91 items on a 6-level rating scale representing 11 scales. The German version achieved an Cronbach's Alpha between α = 0.73 and α = 0.93 in a sample of anorexic and bulimic patients, the test-retest reliability ranged from rtt = 0.81 to rtt = 0.89 [28]. In the current study, the three subscales (23 items) with the most relevant content for the symptoms of eating disorders were applied and Cronbach’s Alpha of these scales reached α = 0.91 for “drive for thinness”, α = 0.95 for “bulimia” and α = 0.93 for “body dissatisfaction” in the study population. The quality of the relationship with the parents was measured with the Parental-Representation-Screening-Questionnaire (PRSQ); German Version [Elternbildfragebogen für Kinder- und Jugendliche (EBF-KJ)] for children and adolescents [32]. This German questionnaire, which was applied in this study in its original version, consists of 36 items answered on a 5-level Likert scale and contains three resource-scales (“cohesion”, “identification”, “autonomy”), five risk-scales (“conflicts”, “rejection/ neglect”, “punishment”, “emotional burden”, “fears/overprotection”) and one additional scale “aid”. The Cronbach's Alpha of this validated version were between α = 0.60 and α = 0.85 for students and between α = 0.73 and α = 0.90 for patients [32]. Due to the quantitative evaluation of our study, items with an open response form were not used and for reasons of content, three subscales were not included for analysis of this study (25 instead of 36 items were evaluated). In the current sample, following reliabilities were measured related to the mother or the father: “cohesion” α = 0.92 or α = 0.89, “identification” α = 0.80 or α = 0.87, “autonomy” α = 0.69 or α = 0.81, “conflicts” α = 0.85 or α = 0.83, “punishment” α = 0.82 or α = 0.54, “rejection/neglect” α = 0.90 or α = 0.81, “emotional burden” α = 0.77 or α = 0.84, “fears/overprotection” α = 0.84 or α = 0.85 and “aid” α = 0.73 or α = 0.56.

The Child Feeding Questionnaire for adolescents (CFQ-A) [33] which is an adaption from the CFQ for parents of adolescents [34] and the CFQ for parents of children ranging in age from about 2 to 11 years [35], was used to assess the perceptions of the feeding practices that parents/caregivers used when participants were between 10 and 13 years of age. The Cronbach's Alpha of the English original version of the CFQ-A were α = 0.68 for the scale “responsibility”, α = 0.90 for “monitoring”, α = 0.63 for “pressure to eat” and α = 0.85 for “restriction” [33]. For the purpose of this study, the CFQ-A questionnaire was translated into German language. The 19 items rated on a Likert scale are reflected on four subscales with following internal consistencies in the present sample: “perceived feeding responsibility” (after elimination of item 1) α = 0.80, “monitoring” α = 0.90, “pressure to eat” α = 0.84 and “restriction” α = 0.87.

The Junior Temperament and Character Inventory 12–18 R [36] provides an evaluation of personality in adolescents. The questionnaire consists of 103 items, which are answered on a Likert scale. The German original version of the questionnaire showed internal consistencies between α = 0.79 and α = 0.85 [36]. Only several contently relevant scales were evaluated. In the current study an internal consistency of α = 0.90 for “harm avoidance”, α = 0.91 for “self-directedness” and α = 0.90 for “self-acceptance” was calculated.

Statistical analysis

The data was evaluated using IBM SPSS Statistics 24. The parental relationship of females with ED and HC were calculated using the t-test for heterogeneous variances (Welch test) and effect sizes according to Cohen. To examine the association of an ED with the relationship with the parent, a binary logistic regression with a stepwise backward method according to Wald was calculated in the total sample (ED and HC). Nagelkerke’s R2 was used to check the classification quality. A value > 40% can be regarded as good. The relationship between “rejection/neglect” and “self-acceptance” was calculated using the Spearman correlation (two-sided testing). The mediator analysis was calculated in the total sample (ED and HC) and therefore PROCESS 2.16.3 according to Hayes for SPSS® was applied with the criteria “drive for thinness” in relation to maternal relationship quality.

The parental influence on diet at the age of 10–13 years for females with ED and HC was compared bilaterally using the Welch test.

A power calculation was performed on the basis of the assumption of a difference of 4.5 points between females with ED and HC on the subscale “rejection/neglect” of the Parental-Representation-Screening-Questionnaire (PRSQ) and a confidence level of 95%. Mean values of school kids with normal parental representation (M 49 ± 4.8) and a psychiatric patient group with normal and abnormal parental representations (M 53.5) were derived from literature [9]. This showed that to obtain a power of 80% for the detection of significant differences, a minimum sample size of 18 patients per group was required.

Results

Sample description

A total of 52 females were included in the study. Of these, 30 participants were included into the healthy control group (HC), while 22 adolescent and young adults were included into the eating disorders group (ED). In the group of participants in whom clinicians diagnosed an eating disorder (ED) according to the criteria of the ICD-10, one participant had to be excluded due to lack of data and 21 persons could be subjected to further analyses. In the healthy control (HC) group, 8 participants were excluded as they were classified as “at risk of developing an ED” due to symptoms of disordered eating (according to EDI-2). The data of 22 HCs could be further analysed. Due to missing values, the sample size varied in the individual calculations.

The age of the study participants was between 16 and 26 years with a similar distribution in both groups (HC: M = 18.55 ± 2.67; ED: M = 18.86 ± 2.72). The Body Mass Index (BMI) was M = 22.63 for the HC group and M = 18.30 for the ED group. A BMI less than 18.50 was classified as underweight.

In the ED group, 17 (80.9%) females had been diagnosed with anorexia nervosa while four (19.1%) females had been diagnosed with bulimia nervosa. One person from the ED-group also suffered from depression. The onset of the ED was between 10 and 19 years (M = 15 ± 1.97). Of the participants with an ED, 21 (100%) were currently in psychological or psychiatric treatment. Persons in the HC group did not suffer from any diagnosed mental health disorder.

Relationship with parents

With regard to the quality of the relationship with the mother, significant differences were revealed between the groups (ED n = 21, HC n = 22) for the scales “rejection/neglect” (t(24.75) = - 2.13, p = 0.043, d = - 0.65) and “fears/overprotection” (t(38.72) = - 3.01, p = 0.005, d = - 0.92). The results are demonstrated in Table 1. No significant differences could be demonstrated for the relationship with the mother for each group in “cohesion” (ED and HC) (t(40.32) = 0.95, p = 0.394, d = 0) 0.29), “autonomy”, (t(40.96) = 0.67, p = 0.504, d = 0.20), “conflicts” (t(40.85) = - 0.83, p = 0.410, d = - 0.25), and “emotional burden” (t(39.94) = 0.37, p = 0.714, d = 0.11). There was no significant difference in any scale between these two groups in terms of the quality of the relationship with the father.

Table 1

Differences in relationship quality with the mother between females without eating disorders (HC) and females with eating disorders (ED).

Scale	Mean value (SD)		t	p	d
	HC	ED
	(n = 22)	(n = 21)
Cohesion	3.12 (±0.96)	2.83 (±1.04)	0.95	0.349	0.29
Autonomy	2.89 (±0.69)	2.75 (±0.64)	0.67	0.252	0.20
Conflicts	1.77 (±0.85)	1.97 (±0.76)	- 0.83	0.410	-0.25
Rejection/neglect	0.11 (±0.25)	0.46 (±0.71)	- 2.13	0.022*	-0.65
Emotional burden	1.35 (±0.75)	1.26 (±0.85)	0.37	0.714	0.11
Fears/overprotection	1.58 (±0.78)	2.38 (±0.95)	- 3.01	0.003*	- 0.92

Average values, standard deviations (±SD), p-values and effect strengths (d) of the relationship to the mother are displayed.

Based on values from 0 to 4, meaning very low to high.

*p < 0.05, one-sided.

Association of an eating disorder: Relationship with the mother

The variables “conflicts”, “emotional burden”, “autonomy”, “cohesion”, “rejection/neglect” and “fears/overprotection” of the mother were investigated by means of binary logistic regression (n = 42; see Table 2). It was found that young females who perceived more “cohesion”, “rejection/neglect” and “fears/overprotection” by their mother more often suffered from an ED. The model explained 43.9% of the variance.

Table 2

Predictors for the presence of an eating disorder.

	B	SE	Forest χ2 (df = 1)	p	OR
Cohesion	1.40	0.72	3.73	0.053	4.04
Rejection/Neglect	3.38	1.49	5.15	0.023*	29.35
Fears/Overprotection	1.45	0.54	7.07	0.008*	4.24
Constant	- 7.92	3.18	6.21	0.013*	0.00

Coefficients and test quantities of binary logistic regression (using the exclusion method).

Significance level: α = 10%. Excluded: Conflicts, “emotional burden”, autonomy. B = unstandardized regression coefficient. OR = Odds ratio. n = 43.

Mediators between maternal relationship and symptoms of eating disorders

The mediation model tries to identify a possible process that underlies the observed relationship between the independent variable “relationship with the mother” and the dependent variable “symptoms of eating disorders” via the inclusion of a third hypothetical mediator variable “personality traits”. In this study, analyses were only carried out for variables with strong correlations in previous calculations. For eating disorder symptoms, a separate analysis was done with the criteria "body dissatisfaction" and "drive for thinness" since it was not reasonable to combine these two scales to a common scale. Since there was no significant association between “autonomy” and the mediator “self-directedness” (r = 0.08, p = 0.627, n = 42), nor between “autonomy” and the criteria “body dissatisfaction” (r = - 0.08, p = 0.586, n = 43) / “drive for thinness” (r = 0.00, p = 0.995, n = 43), there can be no mediation and therefore, no analysis was carried out. The applied scales were tested for z-standardization before the analysis and with regard to the procedural requirements, the normal distribution of the data could generally be assumed on the basis of the validity of the central limit theorem for sample sizes ≥ 30.

The mediator analysis (n = 42) found a direct and an indirect effect of “fears/overprotection” on the "drive for thinness" via anxious personality traits ("harm avoidance"). The direct effect measures the extent to which “fears/overprotection” changes when “drive for thinness” increases and the mediator variable remains unaltered. In contrast, the indirect effect measures the extent to which “drive for thinness” changes when “fears/overprotection” is held fixed and “harm avoidance” changes by the amount it would have changed had “fears/overprotection” increased by one unit. Part of the effect was mediated indirectly through the mediator “harm avoidance” (β = 0.14) and part of the effect was directly mediated from “fears/overprotection” to “drive for thinness” (β = 0.41), together they had a medium effect (β = 0.55). Fig 1 shows the relationships embedded in the model and gives the statistical parameters of the effects. The effect of “fears/overprotection” on “body dissatisfaction” was not mediated by “harm avoidance” (β = 0.07).

Fig 1

Mediator model fears/overprotection—harm avoidance—drive for thinness.

*p<0.05. n = 42. β = standardized regression coefficient, indirect effect β .14, boot SE 0.08, BootLLCI (t) 0.01 a, BootULCI (p) 0.36 a, aconfidence interval 0 not included, therefore effect significant Bootstrap: 5000.

Parental feeding practices at the age of 10–13 years

The scales “monitoring” (t(39.41) = - 0.78, p = 0.443, d = - 0.24), “pressure to eat”(t(33.03) = - 1.55, p = 0.131, d = - 0.47) and “restriction” (t(35.35) = - 1.55, p = 0.129, d = - 0.47) showed no significant differences. Only the scale “perceived feeding responsibility” showed a significant difference between the two groups (t(39.67) = - 2.20, p = 0.034, d = - 0.67). Female adolescents and young adults with an ED reported that they had less personal responsibility at the age of 10–13 years for what and how much they ate in comparison to females without an ED (see Table 3).

Table 3

Comparison of perceived parental influence on diet at the age of 10–13 for females without eating disorder (HC) and females with eating disorder (ED).

Scale	Mean value (SD)		t	p	D
	HC	ED
	(n = 22)	(n = 21)
Perceived feeding responsibility	2.20 (0.93)	2.88 (1.07)	- 2.20	0.034*	- 0.67
Monitoring	2.95 (1.10)	3.24 (1.29)	- 0.78	0.443	- 0.24
Pressure to eat	2.37 (0.77)	2.87 (1.24)	- 1.55	0.131	- 0.47
Restriction	1.96 (0.68)	2.36 (0.98)	- 1.55	0.129	- 0.47

Based on values from 1 to 5, meaning very low to very high. p ≤ 0.05, two-sided.

Relationship between parental rejection/neglect and self-acceptance

A significantly negative correlation between the scale “rejection/neglect” of the mother and “self-acceptance” of the test subjects could be determined (rs = - 0.35, p = 0.022, n = 42). There was also a significant negative correlation between the fathers’ “rejection/neglect” and “self-acceptance” (rs = - 0.47, p = 0.002, n = 42). This means that more rejection/neglect by both the mother and the father was accompanied by less self-acceptance of young females with an even greater influence of the fathers’ rejection/neglect.

Discussion

The aim of the study was to investigate a possible association between eating disorders (ED) and subjective stress in the relationship with parents as well as retrospective parental influence on eating behaviour at the early adolescence from the perspective of affected young females.

Adolescents and young adult females with ED reported more fears/overprotection and rejection/neglect by their mothers and less self-responsibility regarding eating behaviour in adolescence than healthy young females. The relationship with fathers did not differ significantly. It was shown that young women who perceived more cohesion, rejection/neglect and fears/overprotection from their mothers had an increased chance of suffering from an eating disorder. Rejection or neglect by the mothers and the fathers was associated with lower self-acceptance among young females, while the influence of father's rejection/neglect on self-confidence was even greater.

According to the attachment theory, a well-functioning relationship with parents is crucial for children to learn self-acceptance and independent emotion regulation in adolescence–both of which are known to influence the development of eating disorders in adolescence [13]. Previous research have focused on parental functioning in families of patients with ED, with a particular emphasis on the links between the psychopathological symptoms of mothers and daughters. However, only few and often contradictory findings exist on whether there are specific maladaptive psychological profiles characterizing the family structure as a whole when it includes adolescent and young adult females with anorexia nervosa (AN) or bulimia nervosa (BN) [37]. In our study, we expected to find an association of EDs and problematic family functioning. Furthermore, we expected females with an ED to have experienced significantly more rejection/neglect or fears/overprotection from their mothers than females without an ED.

While rejection/neglect or fears/overprotection are contrary relationship patterns, our results indicate that mothers of patients with ED are experienced in different extremes between entanglement and rejection–in part depending on the type of ED.

In previous literature, adolescents with BN were reported to having had a significantly more dysfunctional family background than those with AN [11]. Patients with BN perceived their families as badly organized, and reported the presence of high levels of family conflicts [37]. These conflicts may have led to perceived rejection/neglect from parents. In contrast, in families of adolescents diagnosed with AN, higher conflict avoidance and enmeshment was found. This means that over-concern for others with a loss of autonomous development could lead to fears/overprotection [37]. Literature, however, remains inconclusive as both a tendency towards parental overprotection in EDs [38] as well as no connection between overprotection and EDs have previously been demonstrated [39]. Our results are in agreement with previous literature where a general tendency towards more perceived parental rejection in persons with an ED was postulated [16, 18, 19].

The results regarding the father-daughter relationship and eating disorders are of particular interest. A recent review [40] identified a gap in the literature regarding this topic and called for research to further investigate this dyadic relationship. The father-daughter relationship is important during adolescence as it plays a role in the development of autonomy and self-esteem, both of them are involved in eating disorder psychopathology [40].

In our study, it could be shown that rejection or neglect by both mother and father was accompanied by less self-acceptance on the part of the young females. No direct connection could be found between the quality of the relationship with the father and the presence of an ED. However, an indirect effect of fathers on the symptoms of EDs was shown, since subjectively perceived rejection or neglect by the father was accompanied by less self-acceptance on the part of the young females. The paternal influence on self-acceptance was even greater than that of the mothers. Interestingly, a recent study found that changes in the perceived quality of the father–adolescent daughter attachment relationship were only associated with daughters’ self-esteem (not to that of the sons’) [41]. As attachment theory indicates, exploration and security represent two sides of a secure attachment style [12], and, according to traditional role models, fathers are seen as more independence encouraging (while mothers serve as a haven of safety). But some changes to the father–daughter attachment can be observed when girls approach adolescence. In adolescence, daughters may increasingly start to value their fathers’ independence-encouraging behaviour. This makes them more susceptible for shortcomings in the perceived quality of the father–child attachment relationship [12, 40].

Harm avoidance as an adolescent and young adult females’ personality trait in part mediated the direct influence of the fears/overprotection of the mothers on aspects of the ED symptoms of the young females. Parents exercised some control over the young females’ drive for thinness through experienced overprotection, which was influenced by their own control in the form of harm avoidance. Stenbæk [15] found a similar influence of the personality trait harm avoidance, which had a mediating effect on the direct influence of parental overprotection and perceived stress or susceptibility to psychological symptoms in healthy adults. It has also been shown that self-regulating skills, such as self-compassion, moderate the impact of perfectionism on disordered eating [22].

In this study, in advance, we expected that female adolescents and young adults with ED will report about more experienced and stricter regulations on dieting than HC. Interestingly, the female adolescent and young adults with EDs reported significantly less feeding responsibility in early adolescence compared to the females in the HC group, but other characteristics of controlling parental feeding practices like food restrictions, monitoring during meal and the pressure to eat did not show significant difference in both groups. Previous studies had shown restrictive parental feeding practices to increase the likelihood of disordered eating [25, 26]. If excessive parental control over food consumption is applied in raising children, the development of self-regulatory capacities could be negatively influenced [25]. Stringent maternal restriction of food resulted in eating psychopathology such as extreme weight control in daughters [24]. Although we found no such effect of controlling feeding practices such as restriction, pressure to eat and monitoring in our study, we did find an effect on feeding responsibility, which is the opposite of controlling practices of the parents by informing about the freedom to make dietary decisions on behalf of the adolescent females.

Strengths and limitations

A strength of our paper is the innovative study design investigating the perceived parental’ feeding practices in early adolescence in the context of the relationship with the parents in a clinical sample of female adolescent and young adults diagnosed with EDs as well as in healthy participants (HC). To the best of our knowledge, no examination of perceived parental feeding practices, as evaluated in this study adapting the Child Feeding Questionnaire for Adolescents [35], in females with valid diagnoses of EDs according to ICD-10 [29] has yet been conducted by clinicians at ED institutions. Previous studies were carried out in non-clinical population and they mainly investigated the relationship between parental feeding practices and eating disorders psychopathology [35, 42] The DSM-5 [1] has recently also included binge eating disorder (BED) as an autonomous diagnosis characterized by recurrent episodes of eating fits accompanied by a feeling of loss of control but lower interest in body shape or weight. In the present study, we state that the parental relationship is mediated through self-assessment and that self-evaluation is extremely influenced by the symptoms of the eating disorder (such as body shape or weight). Compared to AN and BN, body shape and weight do not seem to play such a central role in regulating self-confidence in the BED, so the BED was not included.

Some limitations do, however, need to be addressed: The cross-sectional design of the present study does not allow causal interpretation and results need to be interpreted with causation. Although the healthy control (HC) group was composed with regard to a similar age distribution as in the group of female adolescents and young adults with eating disorders (ED), no age matching was performed in the analysis.

Furthermore, although a sample size calculation based on group differences of main characteristics had been performed, a relatively small sample size may be interpreted another limitation of our study as only moderate and clear effects, but no small effects may be recorded [43] and results with very high standard deviations should be treated with caution. However, the significant and reliable differences and effect sizes found despite these limitations underline the relevance of the results. Eight people were excluded from the control group due to symptoms of an eating disorder above the threshold, which means that almost one third were affected by the disordered eating behaviour. Therefore, the results of females with ED were not compared with the baseline values of a group representative of the population. The retrospective collection of the data on perceived parental feeding behaviour in early adolescence of females offers limitations due to possible distortions of the remembered influence [44]. The retrospective measurement is another possible weakness of the study, as we cannot rule out possible recall biases involved in the reports of the adolescent and young adult females aged between 18–19 years making statements about parental feeding practices when they were 10–13 years of age. Another limitation is that the Child Feeding Questionnaire for adolescents (CFQ-A) was only translated into German language for this study. To our knowledge there exists no German validated version and therefore we have provided the psychometric properties of our translated version. While the questionnaire was first translated into German by multiple authors and then back translated into an English version for comparability, the translation was not previously validated.

In this study, based on these observations, we assume that female adolescents and young adults with ED have experienced more or stricter regulations on dieting than HC. As our study does not include longitudinal data, only retrospectively assessed recall may be interpreted in our cross-sectional questionnaire study. Previous literature, however, has shown, that cross-sectional studies may infer information of possible influencing factors[27, 45] Nonetheless, results need to be interpreted with caution.

Conclusions

As an eating problem manifests and develops, the signs of disordered eating are enormously stressful for the whole family and it is natural for parents to react with grave concerns. Feeding practices and relationships might be drastically altered in profound ways. A recent meta-analysis underlines difficulties in establishing a therapeutic alliance and highlights especially the risk that professionals, adolescents, and parents will not converse about treatment, although such a dialogue appears to be an essential component in the construction of a therapeutic alliance [46]. As the results of the current study also underline, prevention and treatment efforts with focus on nutritional counselling of parents and stressors in the parent-child relationship should be targeted in particular at young females aged 10–19, at the highest incidence of anorexia and bulimia [44]. The established family therapy of adolescents with EDs [42], which works on dysfunctional parental relationship, and the psychotherapy of adults with EDs, which focuses on self-regulatory mechanism [10], therapeutic relationship and personality development, would also prove useful against the background of the present results. Knowledge about parental influence on eating behaviour and psychosocial development in the context of EDs may be useful in parent counselling and prevention work so that parents can be increasingly seen as a resource in the prevention and treatment of EDs. There is a need for further research with a prospective design and more objective measures like observation by investigators to allow for statements about parental feeding practices/relationship as protective or risk factors in the development of eating disorders.

5 Jun 2020

PONE-D-20-11413

Parental feeding practices and the relationship with parents in young women with eating disorders: A case control study

PLOS ONE

Dear Dr. Werneck,

Thank you for submitting your manuscript to PLOS ONE. After careful consideration, we feel that it has merit but does not fully meet PLOS ONE’s publication criteria as it currently stands. Therefore, we invite you to submit a revised version of the manuscript that addresses the points raised during the review process.

Please submit your revised manuscript by Jul 20 2020 11:59PM. If you will need more time than this to complete your revisions, please reply to this message or contact the journal office at plosone@plos.org. When you're ready to submit your revision, log on to https://www.editorialmanager.com/pone/ and select the 'Submissions Needing Revision' folder to locate your manuscript file.

Please include the following items when submitting your revised manuscript:

A rebuttal letter that responds to each point raised by the academic editor and reviewer(s). You should upload this letter as a separate file labeled 'Response to Reviewers'.

A marked-up copy of your manuscript that highlights changes made to the original version. You should upload this as a separate file labeled 'Revised Manuscript with Track Changes'.

An unmarked version of your revised paper without tracked changes. You should upload this as a separate file labeled 'Manuscript'.

If you would like to make changes to your financial disclosure, please include your updated statement in your cover letter. Guidelines for resubmitting your figure files are available below the reviewer comments at the end of this letter.

If applicable, we recommend that you deposit your laboratory protocols in protocols.io to enhance the reproducibility of your results. Protocols.io assigns your protocol its own identifier (DOI) so that it can be cited independently in the future. For instructions see: http://journals.plos.org/plosone/s/submission-guidelines#loc-laboratory-protocols

We look forward to receiving your revised manuscript.

Kind regards,

Silvia Cimino

Academic Editor

PLOS ONE

Journal Requirements:

When submitting your revision, we need you to address these additional requirements.

1. Please ensure that your manuscript meets PLOS ONE's style requirements, including those for file naming. The PLOS ONE style templates can be found at

https://journals.plos.org/plosone/s/file?id=wjVg/PLOSOne_formatting_sample_main_body.pdf and

https://journals.plos.org/plosone/s/file?id=ba62/PLOSOne_formatting_sample_title_authors_affiliations.pdf

2. Please state in your methods section whether you obtained consent from parents or guardians of the minors (those aged <18) included in the study or whether the research ethics committee or IRB approved the lack of parent or guardian consent.

3. We note that you have indicated that data from this study are available upon request. PLOS only allows data to be available upon request if there are legal or ethical restrictions on sharing data publicly. For information on unacceptable data access restrictions, please see http://journals.plos.org/plosone/s/data-availability#loc-unacceptable-data-access-restrictions.

In your revised cover letter, please address the following prompts:

a) If there are ethical or legal restrictions on sharing a de-identified data set, please explain them in detail (e.g., data contain potentially identifying or sensitive patient information) and who has imposed them (e.g., an ethics committee). Please also provide contact information for a data access committee, ethics committee, or other institutional body to which data requests may be sent.

b) If there are no restrictions, please upload the minimal anonymized data set necessary to replicate your study findings as either Supporting Information files or to a stable, public repository and provide us with the relevant URLs, DOIs, or accession numbers. Please see http://www.bmj.com/content/340/bmj.c181.long for guidelines on how to de-identify and prepare clinical data for publication. For a list of acceptable repositories, please see http://journals.plos.org/plosone/s/data-availability#loc-recommended-repositories.

We will update your Data Availability statement on your behalf to reflect the information you provide.

4. PLOS requires an ORCID iD for the corresponding author in Editorial Manager on papers submitted after December 6th, 2016. Please ensure that you have an ORCID iD and that it is validated in Editorial Manager. To do this, go to ‘Update my Information’ (in the upper left-hand corner of the main menu), and click on the Fetch/Validate link next to the ORCID field. This will take you to the ORCID site and allow you to create a new iD or authenticate a pre-existing iD in Editorial Manager. Please see the following video for instructions on linking an ORCID iD to your Editorial Manager account: https://www.youtube.com/watch?v=_xcclfuvtxQ

5. Your ethics statement must appear in the Methods section of your manuscript. If your ethics statement is written in any section besides the Methods, please move it to the Methods section and delete it from any other section. Please also ensure that your ethics statement is included in your manuscript, as the ethics section of your online submission will not be published alongside your manuscript.

[Note: HTML markup is below. Please do not edit.]

Reviewers' comments:

Reviewer's Responses to Questions

Comments to the Author

1. Is the manuscript technically sound, and do the data support the conclusions?

The manuscript must describe a technically sound piece of scientific research with data that supports the conclusions. Experiments must have been conducted rigorously, with appropriate controls, replication, and sample sizes. The conclusions must be drawn appropriately based on the data presented.

Reviewer #1: Partly

Reviewer #2: No

**********

2. Has the statistical analysis been performed appropriately and rigorously?

Reviewer #1: Yes

Reviewer #2: Yes

**********

3. Have the authors made all data underlying the findings in their manuscript fully available?

The PLOS Data policy requires authors to make all data underlying the findings described in their manuscript fully available without restriction, with rare exception (please refer to the Data Availability Statement in the manuscript PDF file). The data should be provided as part of the manuscript or its supporting information, or deposited to a public repository. For example, in addition to summary statistics, the data points behind means, medians and variance measures should be available. If there are restrictions on publicly sharing data—e.g. participant privacy or use of data from a third party—those must be specified.

Reviewer #1: Yes

Reviewer #2: Yes

**********

4. Is the manuscript presented in an intelligible fashion and written in standard English?

PLOS ONE does not copyedit accepted manuscripts, so the language in submitted articles must be clear, correct, and unambiguous. Any typographical or grammatical errors should be corrected at revision, so please note any specific errors here.

Reviewer #1: No

Reviewer #2: Yes

**********

5. Review Comments to the Author

Please use the space provided to explain your answers to the questions above. You may also include additional comments for the author, including concerns about dual publication, research ethics, or publication ethics. (Please upload your review as an attachment if it exceeds 20,000 characters)

Reviewer #1: Thank you for the opportunity of revising this manuscript titled “Parental feeding practices and the relationship with parents in young women with eating disorders: A case control study’. The study took in consideration, in a sample of young women with and without an eating disorder, the possible association between eating disorders and characteristics of the relationship with parents and the parental feeding practices in early adolescence.

I read the article and I think the focus is very interesting. Despite this, several structural revisions are necessary. So I think that it can be published in this Journal, but with major revision. In particular I think it is important to give evidence to the theoretical model, also illustrating a major study of recent literature. Please find below some comments.

INTRODUCTION

In the introduction, the concept of EDS is introduced, but it is not adequately explained, referring also to the most recent diagnostic classifications (e.g. DSM-5).

Moreover, the adolescent population is the object of interest. However, the authors reported prevalence rates without referring to this specific developmental stage. It's important to report the prevalence rates and the clinical relevance of the phenomenon in adolescence. Moreover, I suggest to cite previous studies that have shown that the peaks of EDS onset are in the adolescent phase. See, for example, the study by Poppe I, Simons A, Glazemakers I, Van West D. Early-onset eating disorders:a review of the literature. Tijdschr Psychiatr. 2015;57(11):805–814. In addition, in the introduction is not specified why adolescence represents a phase of risk for the onset and maintenance of Eating disorders. It would be important to underline the peculiarities of this specific evolutionary stage. We recommend, for example: Baker et al., (2012), “Pubertal development predicts eating behaviors in adolescence” Or Ballarotto et al.(2017). Does alexithymia have a mediating effect between impulsivity and emotional-behavioural functioning in adolescents with binge eating disorder?. Clinical Neuropsychiatry, 14(4).

Moreover, from the outset, the theoretical framework should be clear. The authors should describe from the beginning the theoretical framework from which they start for their own study.

On the other hand, the links between parents and children are highlighted, but the influence and emotional exchange between parents and children, linked to eating patterns, is not clear. It can be helpful for a review, see the study: Cimino et al.(2018). Impact of parental binge eating disorder: exploring children's emotional/behavioral problems and the quality of parent–child feeding interactions. Infant mental health journal, 39(5), 552-568.

The aims of the study are not clear. For example, the statistical analysis section showed that you also tested a mediation model, but it is not clear on the basis of which hypotheses. I suggest that you reorganize the last part of the introduction, describing the objectives of the study in detail. For each aim, it is also important to specify what the hypotheses are, and based on which previous studies and theoretical perspective.

This is not a longitudinal study, so authors should clarify already in the introduction because, and on the basis of which literature, it is possible to draw cause-effect conclusions in retrospective or cross-sectional studies. See, for example, the study by “Cox, D. R. (1992). Causality: some statistical aspects. Journal of the Royal Statistical Society: Series A (Statistics in Society), 155(2), 291-301” and the study by “Wunsch, G., Russo, F., & Mouchart, M. (2010). Do we necessarily need longitudinal data to infer causal relations?. Bulletin of Sociological Methodology/Bulletin de Méthodologie Sociologique, 106(1), 5-18.”

METHODS

In the subsection of “Sample and participant selection” it is important to specify where the clinical and healthy sample has been recruited.

It is also important to better clarify the specific inclusion/exclusion criteria of both the clinical group and the healthy group.

What did you use to collect demographic information? Did you build a questionnaire? Through an interview? It is important to specify this information.

The authors said that they used the Child Feeding Questionnaire for adolescents (CFQ-A), and that, for this study, the questionnaire was translated into German language. There's no German validated version? This is an important limitation of the study, which must be added among the limitations.

For all instruments, it is important to specify if you have used a German validated version. Moreover, the psychometric properties of the original version of the instruments should be reported.

In the section on statistical analysis, it is important to highlight which analyses have been carried out considering the two different groups (ED and HC) and which ones considering the total sample.

RESULTS

The section “Sample description” is confusing and needs to be reorganized. I suggest you initially describe the initial sample you recruited (how many clinical subjects? How many regulatory subjects?). then specify how many cases were excluded from the clinical group, specifying how many for each exclusion criterion. Next, describe how many subjects were excluded from the regulatory group, specifying how many for each exclusion criterion. Finally, describe the characteristics of the final sample, for each of the two groups. Furthermore, it is not clear how many subjects each group is composed of. This information should be added.

In the abstract, the authors referred that the age of the study participants was between 16 and 30 years, but in the results they reported a range between 16 and 26 years. What is the age range of the sample?

Moreover, in the description of mediation results, it is necessary to specify whether the analyses were carried out on the total sample and why.

In the comments of table 1, it is not clear what the phrase "Based on values from 0 = never to 4 = always" refers to. At the same time, in the comments of table 3, it is not clear what the phrase “Based on values from 1 = never / does not apply at all to 10 5 = always / applies entirely” refers to.

DISCUSSION

As suggested for the introduction, it is important that the theoretical approach of the authors is best outlined also in the discussion, and that the focus of the work is well exposed.

Most of the results are discussed on the basis of the results of previous studies. However, overall, there is a lack of hypotheses underlying the findings. For example, one of the main strengths of the study was to have considered the role played by the paternal contribution. However, the authors do not refer to studies in the previous literature (Page 14, line 18). I suggest to cite them. At this regard, see for example, the study by Cerniglia et al. (2017), Family profiles in eating disorders: family functioning and psychopathology. Psychology research and behavior management, 10, 305.

Overall, It is necessary to enrich the discussion of each result of the study by providing possible theoretical explanations.

Page 15, Line 7, there is a typing error. “Stenbæk et al. (8)” should be “Stenbæk et al. (8)”

Reviewer #2: Dear editor,

Thank you very much for the invitation to review the manuscript entitled “Parental feeding practices and the relationship with parents in young women with eating disorders: A case control study”.

I read with very much interest the paper, that is focused on a topic of growing importance for the clinic and research.

Actually, in fact, eating disorders represent a very relevant issue in the international scientific literature. In particular, many researchers have concentrated their interest on the phenomenon of problematic behaviors in various specific developmental ages, such as adolescence and youth.

My overall impression on the manuscript is positive.

Firstly, the authors in their work discuss the topic of eating disorders in adolescents and young women highlighting the relevance of family environment in this complex type of disease. Moreover, specifically, they focus the interest of research on family relationships and parental feeding practices as very relevant aspects that should be taken into account to better understand the son’s sufferance and to organize appropriate intervention strategies.

The writing is overall understandable and the study appears to be sound (form and contents are quite clear). The introduction section, the general aim and results are clearly recognized. Moreover, the use of written English is quite good and clear.

These elements as a whole represents a manuscript’s strengths.

For the above considerations, I think that this work can improve the field of eating disorders, precisely the topic of the relationship between parental dynamics and psychopathological offspring’s well-being.

Nevertheless, I would like to discuss some areas of improvement in the manuscript, so that the authors can use the following comments to review their paper.

______________________________________________________________________________

Title

The title in the full version is perhaps too long and lengthy. The expression Parental feeding practices and the relationship with parents could be replaced with a more general expression that indicate the core theme of the study (family relationships?-family interaction? ecc..)

Maybe the words young women, in the title, don’t refer to the real sample of the study, that also consists in adolescents?

Abstract

Since the age of subjects participating in the study ranges from 16 to 30 years old, the authors should better specify in the text the use of the terms woman-women and adolescents.

Introduction

In the first part of introduction, some aspects appear to be unclear. Authors should include more information about the developmental age of adolescence and youth, also specifying epidemiological data (for instance, about gender differences).

Thus, in the introduction it may be useful to insert a first part on the topic of adolescence by indicating the crucial aspects of this phase of lifecycle, such as the psychological and emotional functioning, the family relationships, the social modifications ecc…). Moreover, I suggest to better clarify the psychological and relational adolescent’s conditions, indicating some empirical contributions on risks and protective factor in adolescence and on family elements.

Moreover, the authors should stress all these aspects of their work by pointing out the focus on relationships in eating disorders, also deepening the related literature: the interest in relationships allows to focus the eating problematic behavior in female adolescents and young women in a systemic perspective, according to which the individual symptom can be understood only within the relational dynamics among family members.

These topics could be better discussed with these works

- Erriu, M., Cimino, S., & Cerniglia, L. (2020). The Role of Family Relationships in Eating Disorders in Adolescents: A Narrative Review. Behavioral Sciences, 10(4), 71.

- Tafà, M., Cimino, S., Ballarotto, G., Bracaglia, F., Bottone, C., & Cerniglia, L. (2017). Female adolescents with eating disorders, parental psychopathological risk and family functioning. Journal of Child and Family Studies, 26(1), 28-39.

-Treasure, J.; Duarte, T.A.; Schmidt, U. Eating disorders. Lancet 2020

In addition, since binge eating disorder (BED) is a specific diagnostic category defined in the DSM V (Apa 2013), it should be rather suggested to write a brief definition of BED clinical features and then to better specify the sample criteria selection (the reasons for the inclusion of anorexia and bulimia in relation to BED).

Finally, the authors should clarify the theoretical framework adopted in relation to the topic of eating disorder in adolescence and youth. Starting from this point, authors should be better articulate the specific hypothesis and objectives of the research.

Method

The section on method could be improved in the choice of titles to be given to subsections.

A possible articulation could be the following:

Research Methods

-Subjects and procedure

-Measures

-Statistical analysis

It would be convenient to better define the selection of the specific sample study (why the age of adolescents starts at 16? And why the age range is from 16 to 30 years?).

Moreover, I suggest to add some additional information about the recruitment procedure.

Results and conclusions

I think the link between the introduction section and the final section is not very clear.

The introduction section should contain a more precise definition of the hypotheses of the research, objectives and variables. The conclusion section should discuss results in relation to the premises. More precisely, in the conclusions the authors should better explain how the findings are related to their initial assumptions.

Finally, since the study is not defined as longitudinal but retrospective research, the authors should better discuss this element.

**********

6. PLOS authors have the option to publish the peer review history of their article (what does this mean?). If published, this will include your full peer review and any attached files.

If you choose “no”, your identity will remain anonymous but your review may still be made public.

Do you want your identity to be public for this peer review? For information about this choice, including consent withdrawal, please see our Privacy Policy.

Reviewer #1: No

Reviewer #2: No

[NOTE: If reviewer comments were submitted as an attachment file, they will be attached to this email and accessible via the submission site. Please log into your account, locate the manuscript record, and check for the action link "View Attachments". If this link does not appear, there are no attachment files.]

While revising your submission, please upload your figure files to the Preflight Analysis and Conversion Engine (PACE) digital diagnostic tool, https://pacev2.apexcovantage.com/. PACE helps ensure that figures meet PLOS requirements. To use PACE, you must first register as a user. Registration is free. Then, login and navigate to the UPLOAD tab, where you will find detailed instructions on how to use the tool. If you encounter any issues or have any questions when using PACE, please email PLOS at figures@plos.org. Please note that Supporting Information files do not need this step.

27 Oct 2020

When submitting your revision, we need you to address these additional

requirements.

1. Please ensure that your manuscript meets PLOS ONE's style

requirements, including those for file naming.

Dear editorial staff at PLOSone! Thank you for bringing this to our attention: We made changes to meet PLOS ONE`s style (e.g. adaptation of level headings).

2. Please state in your methods section whether you obtained consent from parents or guardians of the minors (those aged <18) included in the study or whether the research ethics committee or IRB approved the lack of parent or guardian consent.

Dear editorial team at PLOSone: Thank you! We have now tried to more clearly state the information required. Please see page 7, section „Study Setting“

3. We note that you have indicated that data from this study are available upon request. PLOS only allows data to be available upon request if there are legal or ethical restrictions on sharing data publicly. For information on unacceptable data access restrictions, please see

Dear editorial team at PLOSone: Thank you for this additional information! We have now tried to include a more detailed information on data availability (see page 23, Section „Availability of Data and Materials“, lines 13-16)

In your revised cover letter, please address the following prompts:

a) If there are ethical or legal restrictions on sharing a de-identified data set, please explain them in detail (e.g., data contain potentially identifying or sensitive patient information) and who has imposed them (e.g., an ethics committee). Please also provide contact information for a data access committee, ethics committee, or other institutional body to which data requests may be sent.

b) If there are no restrictions, please upload the minimal anonymized data set necessary to replicate your study findings as either Supporting Information files or to a stable, public repository and provide us with the relevant URLs, DOIs, or accession numbers. Please see http://www.bmj.com/content/340/bmj.c181.long for guidelines on how to de-identify and prepare clinical data for publication. For a list of acceptable repositories, please see http://journals.plos.org/plosone/s/data-availability#loc-recommended-repositories [3].

We will update your Data Availability statement on your behalf to reflect the information you provide.

4. PLOS requires an ORCID iD for the corresponding author in Editorial Manager on papers submitted after December 6th, 2016. Please ensure that you have an ORCID iD and that it is validated in Editorial Manager. To do this, go to ‘Update my Information’ (in the upper left-hand corner of the main menu), and click on the Fetch/Validate link next to the ORCID field. This will take you to the ORCID site and allow you to create a new iD or authenticate a pre-existing iD in Editorial Manager. Please see the following video for instructions on linking an ORCID iD to your Editorial Manager account: https://www.youtube.com/watch?v=_xcclfuvtxQ

Dear editorial team at PLOSone: Thank you! We have updated the author information accordingly!

5. Your ethics statement must appear in the Methods section of your manuscript. If your ethics statement is written in any section besides the Methods, please move it to the Methods section and delete it from any other section. Please also ensure that your ethics statement is included in your manuscript, as the ethics section of your online submission will not be published alongside your manuscript.

Dear editorial team at PLOSone: Thank you! We have now tried to make the information more visible. (see page 7, lines 9-16)

Reviewers' comments:

Reviewer #1:

Thank you for the opportunity of revising this manuscript titled “Parental feeding practices and the relationship with parents in young women with eating disorders: A case control study’. The study took in consideration, in a sample of young women with and without an eating disorder, the possible association between eating disorders and characteristics of the relationship with parents and the parental feeding practices in early adolescence.

Dear Reviewer: We thank you for taking the time to send a very thoughtful and thorough review! We have strived to enact changes according to your comments. In their entirety, we feel, that the paper has gained in preciseness and quality by doing so! For all comments, that were answered positively and in full, we have marked these in *green* color.

I read the article and I think the focus is very interesting.

Thank you!

Despite this, several structural revisions are necessary. So, I think that it can be published in this Journal, but with major revision. In particular I think it is important to give evidence to the theoretical model, also illustrating a major study of recent literature. Please find below some comments.

We again, thank you for a very thoughtful and thorough review!

INTRODUCTION

In the introduction, the concept of EDS is introduced, but it is not adequately explained, referring also to the most recent diagnostic classifications (e.g. DSM-5).

Thank you! It is correct, that we had not previously described the individual entities of eating disorders (in part so “safe space”). We have now included – at the beginning of the Introduction – paragraphs concerning the eating disorder definitions

Moreover, the adolescent population is the object of interest. However, the authors reported prevalence rates without referring to this specific developmental stage. It's important to report the prevalence rates and the clinical relevance of the phenomenon in adolescence. Moreover, I suggest to cite previous studies that have shown that the peaks of EDS onset are in the adolescent phase. See, for example, the study by Poppe I, Simons A, Glazemakers I, Van West D. Early-onset eating disorders:a review of the literature. Tijdschr Psychiatr. 2015;57(11):805–814.

Thank you! We have now strived to present a more nuanced presentation of prevalence according to the age group of interest and have now also included references to risinig rates of prevalence.

In addition, in the introduction is not specified why adolescence represents a phase of risk for the onset and maintenance of Eating disorders. It would be important to underline the peculiarities of this specific evolutionary stage. We recommend, for example: Baker et al.,

(2012), “Pubertal development predicts eating behaviors in adolescence” Or Ballarotto et al.(2017). Does alexithymia have a mediating effect between impulsivity and emotional-behavioural functioning in adolescents with binge eating disorder?. Clinical Neuropsychiatry, 14(4).

Thank you! You are correct in stating the importance of these aspects! We have created a section on adolescents as a risk factor and the mentioned author’s papers in the introduction as well as the discussion!

Moreover, from the outset, the theoretical framework should be clear. The authors should describe from the beginning the theoretical framework from which they start for their own study.

We have now included a section on theoretical framework.

On the other hand, the links between parents and children are highlighted, but the influence and emotional exchange between parents and children, linked to eating patterns, is not clear. It can be helpful for a review, see the study: Cimino et al.(2018). Impact of parental binge eating disorder: exploring children's emotional/behavioral problems and the quality of parent–child feeding interactions. Infant mental health journal, 39(5), 552-568.

Thank you for this suggestion! We have included a section on this and we feel, that it has gained in relevance by doing so!

The aims of the study are not clear. For example, the statistical analysis section showed that you also tested a mediation model, but it is not clear on the basis of which hypotheses. I suggest that you reorganize the last part of the introduction, describing the objectives of the study in detail. For each aim, it is also important to specify what the hypotheses are, and based on which previous studies and theoretical perspective.

Thank you for this suggestion! We have seen, that – in some areas – a further clarification was necessary. We have now reorganized the final passage of the introduction. Furthermore, the aims section has been specified and clarified on which previous studies they are based. In its entirety, we hope, that our revised manuscript more closely reflects our intentions.

This is not a longitudinal study, so authors should clarify already in the introduction because, and on the basis of which literature, it is possible to draw cause-effect conclusions in retrospective or cross-sectional studies. See, for example, the study by “Cox, D. R. (1992). Causality: some statistical aspects. Journal of the Royal Statistical Society: Series A (Statistics in Society), 155(2), 291-301” and the study by “Wunsch, G., Russo, F., & Mouchart, M. (2010). Do we necessarily need longitudinal data to infer causal relations?. Bulletin of Sociological Methodology/Bulletin de Méthodologie Sociologique, 106(1), 5-18.”

Thank you for this suggestion! It has been clarified that it is possible to draw cause-effect conclusions not only in longitudinal studies, by using a structural modelling strategy.

METHODS

In the subsection of “Sample and participant selection” it is important to specify where the clinical and healthy sample has been recruited. It is also important to better clarify the specific inclusion/exclusion criteria of both the clinical group and the healthy group.

Thank you for pointing out, that this information had been presented in a too short and incomplete form in the previous version! We have now expanded this section, describing inclusion/exclusion and recruitment!

What did you use to collect demographic information? Did you build a questionnaire? Through an interview? It is important to specify this information.

Again, we need to thank you to point out that this information had been omitted previously. We have now added a paragraph in the Methods-section describing the acquisition of demographic data. We have used our own additional one-page questionnaire for this purpose.

The authors said that they used the Child Feeding Questionnaire for adolescents (CFQ-A), and that, for this study, the questionnaire was translated into German language. There's no German validated version? This is an important limitation of the study, which must be added among the limitations. For all instruments, it is important to specify if you have used a German validated version. Moreover, the psychometric properties of the original version of the instruments should be reported.

Pointing out the possible limitation is of course correct! We had previously not mentioned the limitation as extensive as in the current version: the CFQ-A was used in a German translation made only for this study. In the interest of future studies, we have included the psychometric properties of the original as well as the translated version. We have, as suggested, included a paragraph in the limitations-section of the paper!

For all other tests, the psychometric properties were already included in the paper.

In the section on statistical analysis, it is important to highlight which analyses have been carried out considering the two different groups (ED and HC) and which ones considering the total sample.

Thank you! That is a very observant and valid point! We have now included statement on how many participants were included in the individual analysis

RESULTS

The section “Sample description” is confusing and needs to be reorganized. I suggest you initially describe the initial sample you recruited (how many clinical subjects? How many regulatory subjects?). then specify how many cases were excluded from the clinical group, specifying how many for each exclusion criterion. Next, describe how many subjects were excluded from the regulatory group, specifying how many for each exclusion criterion. Finally, describe the characteristics of the final sample, for each of the two groups. Furthermore, it is not clear how many subjects each group is composed of. This information should be added.

Thank you! We like to extend our gratitude to you for taking the time to help us in organizing the text in a more appropriate fashion! We have restructured the paragraph as mentioned!

In the abstract, the authors referred that the age of the study participants was between 16 and 30 years, but in the results they reported a range between 16 and 26 years. What is the age range of the sample?

That is very observant! In an earlier version of the text it had – most likely – been rounded up! We have now corrected this mistake in the abstract!

Moreover, in the description of mediation results, it is necessary to specify whether the analyses were carried out on the total sample and why.

Thank you! That is correct! As stated in a previous comment-answer, we have now included the requested information.

In the comments of table 1, it is not clear what the phrase "Based on values from 0 = never to 4 = always" refers to. At the same time, in the comments of table 3, it is not clear what the phrase “Based on values from 1 = never / does not apply at all to 10 5 = always / applies

entirely” refers to.

Again, that is very observant of you! Thank you for pointing this out! We have now re-phrased and reformatted the section concerned.

DISCUSSION

As suggested for the introduction, it is important that the theoretical approach of the authors is best outlined also in the discussion, and that the focus of the work is well exposed.

Thank you!

Most of the results are discussed on the basis of the results of previous studies. However, overall, there is a lack of hypotheses underlying the findings. For example, one of the main strengths of the study was to have considered the role played by the paternal contribution. However, the authors do not refer to studies in the previous literature (Page 14, line 18). I suggest to cite them. At this regard, see for example, the study by Cerniglia et al. (2017), Family

profiles in eating disorders: family functioning and psychopathology. Psychology research and behavior management, 10, 305.

Thank you for this suggestion! We have now included the studies mentioned in our discussion and expanded the concerning sections!

Overall, It is necessary to enrich the discussion of each result of the study by providing possible theoretical explanations.

Thank you! We have now expanded the theoretical background!

Page 15, Line 7, there is a typing error. “Stenbæk et al. (8)”

should be “Stenbæk et al. (8)”

Typing was checked again for all authors and their citations.

Reviewer #2: Dear editor,

Thank you very much for the invitation to review the manuscript entitled “Parental feeding practices and the relationship with parents in young women with eating disorders: A case control study”.

I read with very much interest the paper, that is focused on a topic of growing importance for the clinic and research. Actually, in fact, eating disorders represent a very relevant issue in the international scientific literature. In particular, many researchers have concentrated their interest on the phenomenon of problematic behaviors in various specific developmental ages, such as adolescence and youth.

Thank you! We are as well very infested in this field and feel that it is sometimes not as much in the clinical focus as it should be!

My overall impression on the manuscript is positive.

Firstly, the authors in their work discuss the topic of eating disorders in adolescents and young women highlighting the relevance of family environment in this complex type of disease. Moreover, specifically, they focus the interest of research on family relationships and parental feeding practices as very relevant aspects that should be taken into account to better understand the son’s sufferance and to organize appropriate intervention strategies.

Thank you!

The writing is overall understandable and the study appears to be sound (form and contents are quite clear). The introduction section, the general aim and results are clearly recognized. Moreover, the use of written English is quite good and clear.

These elements as a whole represents a manuscript’s strengths. For the above considerations, I think that this work can improve the field of eating disorders, precisely the topic of the relationship between parental dynamics and psychopathological offspring’s well-being.

Again, thank you! We very much appreciate these kind words of support!

Nevertheless, I would like to discuss some areas of improvement in the manuscript, so that the authors can use the following comments to review their paper.

Dear Reviewer! We have strived to follow all of your suggestions and we thank you for your very focused – but still comprehensive! – suggestions! We feel, that the overall quality of the paper was greatly improved!

Title

The title in the full version is perhaps too long and lengthy. The expression Parental feeding practices and the relationship with parents could be replaced with a more general expression that indicate the core theme of the study (family relationships?-family interaction? ecc..) Maybe the words young women, in the title, don’t refer to the real sample of the study, that also consists in adolescents?

That is a very observant and important point. Indeed, we have now, throughout the paper, used more precise wording concerning the study sample and have, thus, also changed the title to incorporate your suggestion!

Abstract

Since the age of subjects participating in the study ranges from 16 to 30 years old, the authors should better specify in the text the use of the terms woman-women and adolescents.

Thank you! As previously mentioned, we have followed your suggestion and changed the wording wherever applicable!

Introduction

In the first part of introduction, some aspects appear to be unclear. Authors should include more information about the developmental age of adolescence and youth, also specifying epidemiological data (for instance, about gender differences). Thus, in the introduction it may be useful to insert a first part on the topic of adolescence by indicating the crucial aspects of this phase of lifecycle, such as the psychological and emotional functioning, the family relationships, the social modifications ecc…). Moreover, I suggest to better clarify the psychological and relational adolescent’s conditions, indicating some empirical contributions on risks and protective factor in adolescence and on family elements. Moreover, the authors should stress all these aspects of their work by pointing out the focus on relationships in eating disorders, also deepening the related literature: the interest in relationships allows to focus the eating problematic behavior in female adolescents and young women in a systemic perspective, according to which the individual symptom can be understood only within the relational dynamics among family members.

These topics could be better discussed with these works

- Erriu, M., Cimino, S., & Cerniglia, L. (2020). The Role of Family Relationships in Eating Disorders in Adolescents: A Narrative Review. Behavioral Sciences, 10(4), 71.

Tafà, M., Cimino, S., Ballarotto, G., Bracaglia, F., Bottone, C., & Cerniglia, L. (2017). Female adolescents with eating disorders, parental psychopathological risk and family functioning. Journal of Child and Family Studies, 26(1), 28-39.

Treasure, J.; Duarte, T.A.; Schmidt, U. Eating disorders. Lancet 2020

Thank you for this thorough review and discussion of possible points of imprevements! We have tried to follow your suggestions and adapted the text now – in some areas extensively. And added the citations suggested!

In addition, since binge eating disorder (BED) is a specific diagnostic category defined in the DSM V (Apa 2013), it should be rather suggested to write a brief definition of BED clinical features and then to better specify the sample criteria selection (the reasons for the inclusion of

anorexia and bulimia in relation to BED).

Thank you for the suggestion! As we have only included AN and BN, but no patients with BED, we have now included a section on criteria of BED and the lack of its inclusion as a possible limitation!

Finally, the authors should clarify the theoretical framework adopted in relation to the topic of eating disorder in adolescence and youth. Starting from this point, authors should be better articulate the specific hypothesis and objectives of the research.

Thank you! As also the other reviewer has pointed out a similar limitation, we have taken the time to rethink how our work is perceived and how we should adapt the presentation of it accordingly to better represent our indented meaning! We have, thus, undertaken a rather extensive revision and feel that, following the suggestions in the reviewprocess, the readability and quality of the paper was improved.

Method

The section on method could be improved in the choice of titles to be given to subsections.

A possible articulation could be the following:

Research Methods

-Subjects and procedure

-Measures

-Statistical analysis

Thank you! We have changed the formatting accordingly!

It would be convenient to better define the selection of the specific sample study (why the age of adolescents starts at 16? And why the age range is from 16 to 30 years?). Moreover, I suggest to add some additional information about the recruitment procedure.

That is a very valid point! We have now added a more extensive description of the process including the inclusion as well as exclusion criteria and how recruitment was undertaken.

We have, also, more clearly defined the age groups. The reason for the age range used was due to pragmatic reasons as these are the ranges most often present in our wards (most often present and of legal age of consent in Austria).

Results and conclusions

I think the link between the introduction section and the final section is not very clear. The introduction section should contain a more precise definition of the hypotheses of the research, objectives and variables. The conclusion section should discuss results in relation to the premises. More precisely, in the conclusions the authors should better explain how the findings are related to their initial assumptions. Finally, since the study is not defined as longitudinal but retrospective research, the authors should better discuss this element.

Thank you for these two suggestions! Indeed, we have seen that our presentation was not optimal, and we have now extensively rewritten some parts according to your suggestions and hope that you will also find, as do we, that the study presentation has been greatly improved by your suggestions!

Submitted filename: Response to Reviewers.docx

Click here for additional data file.

4 Nov 2020

Parental feeding practices and the relationship with parents in female adolescents and young adults with eating disorders: A case control study

PONE-D-20-11413R1

Dear Authors,

We’re pleased to inform you that your manuscript has been judged scientifically suitable for publication and will be formally accepted for publication once it meets all outstanding technical requirements.

Within one week, you’ll receive an e-mail detailing the required amendments. When these have been addressed, you’ll receive a formal acceptance letter and your manuscript will be scheduled for publication.

An invoice for payment will follow shortly after the formal acceptance. To ensure an efficient process, please log into Editorial Manager at http://www.editorialmanager.com/pone/, click the 'Update My Information' link at the top of the page, and double check that your user information is up-to-date. If you have any billing related questions, please contact our Author Billing department directly at authorbilling@plos.org.

If your institution or institutions have a press office, please notify them about your upcoming paper to help maximize its impact. If they’ll be preparing press materials, please inform our press team as soon as possible -- no later than 48 hours after receiving the formal acceptance. Your manuscript will remain under strict press embargo until 2 pm Eastern Time on the date of publication. For more information, please contact onepress@plos.org.

Kind regards,

Silvia Cimino

Academic Editor

PLOS ONE

Additional Editor Comments (optional):

Reviewers' comments:

10 Nov 2020

PONE-D-20-11413R1

Parental feeding practices and the relationship with parents in female adolescents and young adults with eating disorders: A case control study

Dear Dr. Werneck:

I'm pleased to inform you that your manuscript has been deemed suitable for publication in PLOS ONE. Congratulations! Your manuscript is now with our production department.

If your institution or institutions have a press office, please let them know about your upcoming paper now to help maximize its impact. If they'll be preparing press materials, please inform our press team within the next 48 hours. Your manuscript will remain under strict press embargo until 2 pm Eastern Time on the date of publication. For more information please contact onepress@plos.org.

If we can help with anything else, please email us at plosone@plos.org.

Thank you for submitting your work to PLOS ONE and supporting open access.

Kind regards,

PLOS ONE Editorial Office Staff

on behalf of

Professor Silvia Cimino

Academic Editor

PLOS ONE