864121

research-article2019
CCP0010.1177/1359104519864121Clinical Child Psychology and PsychiatryLaporta-Herrero and Latorre

Anorexia Nervosa
Clinical Child Psychology
and Psychiatry
Do parents perceive the abnormal 2020, Vol. 25(1) 5­–15
© The Author(s) 2019
eating attitudes of their adolescent Article reuse guidelines:
sagepub.com/journals-permissions
children with anorexia nervosa? DOI: 10.1177/1359104519864121
https://doi.org/10.1177/1359104519864121
journals.sagepub.com/home/ccp

Isabel Laporta-Herrero1
and Patricia Latorre2
1Facultad de Psicología, Universidad Nacional de Educación a Distancia (UNED), Spain
2Hospital Obispo Polanco, Spain

Abstract
Parents are often the first to detect the initial signs of anorexia nervosa (AN) and take necessary
measures to ensure that their children receive appropriate treatment. The evaluation of AN
in adolescence is complicated by taking into account the tendency to minimize and deny the
symptoms by adolescents, and the difficulty of parents in detecting the main symptoms. We
compared the adolescent and parent scores on measures of disordered eating at initial presentation.
The sample consisted of 62 adolescents diagnosed with AN, who attended an eating disorder
children’s unit. Adolescents completed the Eating Attitudes Test (EAT-40) and their parents
the Anorectic Behavior Observation Scale (ABOS). The questionnaire data were collected as
part of the routine clinical practice and were obtained from clinical notes. The findings indicate
no significant correlations between the EAT-40 and ABOS scores, or between AN subtypes
according to parent observation of symptoms. There were significant differences between
parents, with mothers reporting higher scores than fathers. This study highlights the importance
of psychoeducation for parents on the early signs of AN, in order to improve recognition and
diagnosis at initial assessment of their adolescent children in the early phases.

Keywords
Anorexia nervosa, anorexic behavior, parents, adolescents, children

Introduction
The clinical evaluation of adolescent mental problems requires several informants (Comer &
Kendall, 2004; Kendall & Flannery-Schroeder, 1998). Gathering information from multiple
informants can provide a comprehensive and balanced evaluation of a subject’s behavior, experi-
ence, or functioning, which allows for a more accurate clinical picture (Jepsen, Gray, & Taffe,
2012). However, there is often a discrepancy between informants, especially between parents and

Corresponding author:
Isabel Laporta-Herrero, Facultad de Psicología, Universidad Nacional de Educación a Distancia (UNED), Calle Juan del
Rosal, 14, Madrid 28040, Spain.
Email: isabelaporta@hotmail.com
6 Clinical Child Psychology and Psychiatry 25(1)

children (Achenbach, McConaughy, & Howell, 1987). Generally, a low-to-moderate concordance

has been found in the multi-informative psychological evaluation of the adolescent (De los Reyes
& Kazdin, 2005).
Most previous studies conclude that there is greater parent–child agreement when evaluating
externalizing symptoms (observable behaviors) versus internalizing ones (cognitive, mood, and
physiological elements; Seiffge-Krenke & Kollamr, 1998; van der Meer, Dixon, & Rose, 2008;
Yeh & Weisz, 2001). For example, Salbach-Andrae, Klinkowski, Lenz, and Lehmkuhl (2009)
found a poor to low agreement between parents and adolescents in internalizing disorders and a
moderate agreement on externalizing ones. In their study with a clinical sample of adolescents,
parents tend to emphasize the severity of the difficulties, while adolescents tend to minimize the
symptoms. A study by Cantwell, Lewinsohn, Rohde, and Seeley (1997) with a total of 281 parents–
adolescents found an excellent agreement in the behavioral disorders and central symptom of ano-
rexia; a good agreement in separation anxiety disorder, oppositional-challenging disorder, attention
deficit hyperactivity disorder, substance abuse/dependence, and central symptom of bulimia; and
poor agreement in major depression, dysthymia, anxiety disorders, alcohol abuse/dependence,
bipolar disorder, and obsessive-compulsive disorder. In their study, they concluded that including
parents in the evaluation of the adolescent is useful in the evaluation of externalizing disorders, but
if a single informant has to be chosen, the adolescent would be a better choice.
Discrepancies have been found in the perceptions of fathers and mothers about the problem of
their child. Achenbach et al. (1987) concluded that the agreement was greater between fathers and
mothers in externalizing versus internalizing symptomatology, with mothers reporting the greatest
internalizing problems. Duhig, Renk, Epstein, and Phares (2000) conducted a meta-analysis
focused on the inter-parental agreement. They found moderate correspondence between mothers
and fathers in ratings of internalizing behavior and large correspondence in ratings of externalizing
and total problem behavior. In general terms, the research suggests that mothers report more inter-
nalizing symptomatology than fathers (Grietens et al., 2004; Treutler & Epkins, 2003).
There is a difference found in studies with community samples versus clinical samples
(MacLeod, McNamee, Boyle, Offord, & Friedrich, 1999). In community samples, adolescents
report more internalizing and externalizing behaviors than their parents. However, in clinical sam-
ples, adolescents report less externalizing and more internalizing symptoms than their parents.
These results highlight the importance of the environment, the motivation of the child, and the type
of problem evaluated in the completion of self-report inventories (Smith, 2007). The research sug-
gests that the discrepancy between parents and children can influence the evaluation, classification,
treatment (De los Reyes & Kazdin, 2005) and prognosis of adolescent psychopathology (Ferdinand,
van der Ende, & Verhulst, 2006).
Anorexia nervosa (AN) is an eating disorder (ED) that usually onsets in adolescence (Rohde,
Stice, & Marti, 2015). According to the American Psychiatric Association (APA, 2013), it is deter-
mined by a distortion of the body image, refusal to maintain an equal weight or above the normal
minimum value considering age and size, presence of amenorrhea, and intense fear of weight gain,
which leads to adopt inadequate strategies to prevent increase in the form of excessive physical
exercise and food restriction, called, in this case, restrictive anorexia nervosa (AN-R). If it is also
associated with food binges and/or purging behaviors such as self-induced vomiting or overuse of
laxatives, diuretics, or enemas, it is called anorexia nervosa binge-purge subtype (AN-P).
The beginning of AN is almost imperceptible, and the first signals may seem as a form of self-
discipline and willpower that does not catch the attention of those around them. In addition, psy-
chological aspects that contribute to the disorder, such as emotional problems, low self-esteem,
tendency to extreme perfectionism, overvalued ideas of the body or body image, can go unnoticed
(Lacoste, 2017). Furthermore, people who suffer from the disorder usually adopt a secret attitude,
Laporta-Herrero and Latorre 7

hiding eating disturbances and body shape; for example, using loose clothing, avoiding certain
situations of exposure of their body (e.g. going to the pool or to the beach), or social meetings in
which they may be forced to eat, which leads them to lying, deception, or contradictions. The mini-
mization of symptoms and negation are frequent in AN (Starzomska & Tadeusiewicz, 2016), espe-
cially in the early stages of ED. It has been suggested that although there are behavioral symptoms
in AN, such as self-induced vomiting, diuretic and laxative misuse, and excessive exercise, the
secret and private nature of ED behaviors means that these can be considered as internalizing con-
ditions (Mariano, Watson, Leach, McCormack, & Forbes, 2013).
In adolescence, parents, and other authorities such as educational centers, are one of the key
detectors of the first alarm signals of AN. They can take measures such as seeking professional
help for their children to avoid them from developing ED and receiving appropriate multidiscipli-
nary treatment. Thomson et al. (2014) concluded in their qualitative study that parents require early
advice and support to confirm their suspicions that their children might have AN, and suggested
that they approach the Internet for guidance, and that awareness of useful and accurate websites
could reduce delays in help-seeking. Rome et al. (2003) and Nicholls and Yi (2012) recommend
including the family in the initial assessment of the disorder, from the early stages of diagnosis, as
well as in the treatment process. In addition, studies such as those of Couturier, Lock, Forsberg,
Vanderheyden, and Lee (2007) and Hail (2018) indicate the important role that parents of children
and adolescents can play in identifying restrictive symptomatology and evaluation of AN. On the
other hand, it is known that the prognosis of this disorder improves if it is detected and treated
early, and that one of the predictors of a low response to the treatment of AN is precisely the longest
duration of the disease before being treated (Weigel et al., 2014).
Reviewing the scientific literature on the concordance between parents and children on ED
symptoms, Cantwell et al. (1997) in a community adolescent sample (14–18 years) demonstrated
excellent parent–adolescent agreement in the key indicator of AN, that is, refusal to maintain an
equal weight or above 85%, considering age and size, but only moderate agreement in the key
indicator of bulimia nervosa (BN), that is, frequent binge eating. The study carried out by Steinberg
et al. (2004) on a sample of children from 6 to 12 years old found no agreement between what was
reported by the parents and the children. Parents reported more frequent binge eating than their
children, while the children reported greater compensatory behavior than their parents. On the
other hand, Pendley and Bates (1996) examined the agreement between 319 mothers and daughters
aged 12–15 years in food symptomatology. The results indicated that the mothers underestimated
the symptoms that their daughters referred, emphasizing the difficulty of detecting the food
symptomatology.
In clinical samples, Couturier et al. (2007) conducted an investigation on 117 children and ado-
lescents diagnosed with EDs (AN, BN, and ED not otherwise specified). In the AN group or with
unspecified symptoms of a restrictive type, the scores of the children were significantly lower than
those of their parents in the food restriction and weight preoccupation. Parent–child concordance
was low with respect to AN. The results suggested that patients with AN could underestimate or
not report their own symptoms. In the BN group or with unspecified symptoms of bulimic type, the
children scored higher than their parents in restriction and shape concern. Patients with BN reported
better representation of their symptoms than their parents. They explained that parents might per-
ceive less binging and purging behaviors, and better restriction and excessive physical exercise,
and therefore underestimated the bulimic symptoms presented by their children. In conclusion,
they emphasized the role of parents in the evaluation of AN.
Another more recent study conducted by Mariano et al. (2013) in a sample composed of 619
parents and children found a low to moderate agreement between informants. The parents identi-
fied the presence of behavioral symptoms in their children (except for excessive physical exercise),
8 Clinical Child Psychology and Psychiatry 25(1)

but they referred to the increase in frequency of these symptoms. Children below 12 years of age
reported less anorexic symptoms than their parents, with the reverse effect occurring in adoles-
cents. It was a good concordance between parent and youth scores for AN presentations, but with
no support for the idea that youth with AN presentations would identify less-elevated psychopa-
thology, as was the case in Couturier et al.’s (2007) research.
There is no agreement in previous studies about knowing which of the informants are more reli-
able, parents or children. Smith (2007) proposed a decision-making based on the child’s age
(younger vs older), setting (inpatient vs outpatient), and problem type (internalizing vs external-
izing). Karver (2006) proposed three components, salience to the parent, salience to the child, and
observability/willingness to report, uniquely to prediction of agreement. Diagnostic and Statistical
Manual of Mental Disorders (4th ed.; DSM-4; APA, 1996) prioritizes youth information in the
evaluation and diagnosis of ED; however, Diagnostic and Statistical Manual of Mental Disorders
(5th ed.; DSM-5) widens this criterion to include behavioral observations by other significant peo-
ple, such as parents, to influence diagnosis and clinical formulation (Mariano et al., 2013).
Since the results in previous studies are contradictory, we wondered if parents could be accurate
detectors of the eating symptoms that their children suffered from, or, on the contrary, these symp-
toms were not adequately detected. Therefore, the objectives of this study are as follows:

1. To determine whether the perception of parents on anorexic symptomatology correlates

with the eating symptoms reported by their adolescent children diagnosed with AN. We
hypothesized that the greater the symptomatology referred in children, the greater the
observation of symptoms by their parents.
2. To examine whether there are discrepancies between mothers and fathers on the perception
of anorexic symptomatology. We hypothesized that mothers will identify more anorexic
symptomatology than fathers.
3. To analyze whether there are differences between adolescents diagnosed with AN-R and
those diagnosed with AN-P, based on the parents’ observation of their anorexic behavior.
We hypothesize that parents will perceive the purgative symptomatology less than the
restrictive symptomatology.

Method
Participants
The sample is composed of 62 patients, 90.3% female and 9.7% male, aged between 13 and
17 years (M = 14.81, SD = 1.377). They attended the ED children’s unit at Lozano Blesa University
Hospital in Zaragoza, Aragón, Spain, between 2015 and 2017. The ED unit is the only public unit
in the region (Aragón), so all patients in the unit are referred by the pediatrician for suspected ED.
The ED unit has a multidisciplinary team composed of a psychiatrist, a clinical psychologist, a
nurse, a social worker, and an administrative officer. In the unit, evaluation and diagnosis, medical
and pharmacological treatment, individual and group psychological treatments, and family and
social intervention in people with EDs are carried out. There are two types of treatment: outpatient
program (patients with their family members attend outpatient consultations with psychiatry, clini-
cal psychology, nursing, or social work) and hospitalization (patients are admitted to the hospital’s
brief infancy-juvenile unit of the hospital itself). On reaching the unit, the administrative collects
the sociodemographic data. The clinical psychologist or the psychiatrist conducts the evaluation
interviews for both the children and their parents. All the patients who come to the unit, between
the first and the second day, complete a psychometric evaluation protocol that includes evaluation
Laporta-Herrero and Latorre 9

of the intellectual capacity, presence of anxiety or depression, and ED symptoms (this includes the
Eating Attitudes Test (EAT-40) and the Anorectic Behavior Observation Scale (ABOS)). The clini-
cal psychologist is responsible for applying the protocol and correcting the corresponding ques-
tionnaires/scales, and making a brief report with the results and the diagnostic impression.
Psychiatrists and clinical psychologists, through diagnostic interviews and psychometric evalua-
tion, finally determine the diagnosis of each patient according to DSM-5 (APA, 2013) and the
individualized treatment plan.

Instruments
EAT-40 of Garner and Garfinkel (1981) was adapted and validated in the Spanish population by
Castro, Toro, Salamero, and Guimerá (1991). It evaluates the presence of abnormal eating atti-
tudes, especially those related to the presence of restrictive food patterns, impulse to lose weight,
and fear of weight gain, distributed in three factors: diet, bulimia and concern for food, and oral
control. It is composed of 40 items, with a Likert-type response pattern of 6 points, from 0 (“never”)
to 6 (“always”). The scores range from 0 to 120, with an established cutoff of 30 points (Toro,
Castro, García, Pérez, & Cuesta, 1989).
ABOS of Vandereycken (1992) was validated in the Spanish population by Martin et al. (2013).
It is a self-administered instrument and is completed by the patient’s parents or partner. It evaluates
eating symptomatology and is considered as a useful tool for the screening of changes in eating
behavior, mainly anorexia and bulimia. It is composed of three subscales: eating behavior, related
to weight and food and denial of the problem; bulimic behavior; and hyperactivity. It consists of 30
items, with three response possibilities: “yes” (2 points), “no” (0 points), and “?” (1 point). The
scores range from 0 to 60 points, with 21 being the cutoff point. It shows good internal consistency
with Cronbach’s α of .81 (Martin et al., 2013).

Procedure
This is a quantitative, retrospective, descriptive, and transversal or static design because we are
interested in studying the phenomenon at a specific time.
This study is a part of a larger project called “Attachment, body dissatisfaction and quality of
life in adolescents with eating disorders,” in which 260 patients were selected and whose final
study has not been completed yet. Ethics approval for the study was obtained from the Hospital
Universitario Lozano Blesa de Zaragoza.
The results of the questionnaire scores were retrospectively collected from the clinical histories,
since the data are a part of the routine clinical practice of the ED unit. One of the researchers was
responsible for reviewing all the clinical histories of the patients who were attending the unit at that
moment. Of approximately 300 clinical histories reviewed, 62 patients met the inclusion criteria
detailed below. For methodological and homogenizing issues, the following inclusion criteria were
established: (1) patients between 13 and 17 years, (2) meeting the diagnostic criteria of DSM-5 (APA,
2013) for the diagnostic category of AN (both AN-R and AN-P), and (3) completing the questionnaire
for the patient and at least one parent. The results of the questionnaires, together with the information
of the diagnosis, sex, age, population, and school, were collected by assigning a code to each patient
so that the confidentiality of the information and anonymity were completely guaranteed.
Data were analyzed with the Statistical Package for the Social Sciences (SPSS), Version 19.
Depending on the nature of the variables, we performed descriptive statistics, Pearson’s correla-
tions among the main study variables, Student’s t test for one sample, and another for independent
samples.
10 Clinical Child Psychology and Psychiatry 25(1)

Table 1. Sample demographic and clinical characteristics (n = 62).

Variable Frequency Percentage

Sex
Male 6 9.7
Female 56 90.3
Diagnosis
Restrictive anorexia nervosa 44 71
Binge-purge subtype anorexia nervosa 18 29
Area of residence
Rural 28 45.2
Urban 33 53.2
School
Public 40 64.5
Private 21 33.9

Results
First, we carried out a descriptive analysis of the sociodemographic and clinical characteristics of
the sample. All patients are diagnosed with AN: 71% of AN-R and 29% of AN-P. As for the place
of residence, 45.2% were from a rural location, while 53.2% were from an urban location. All were
students, with 66.1% attending public school compared with 33.9% attending private school (see
Table 1).
We checked the normality of the sample with the Kolmogorov–Smirnov test for a sample. The
results are as follows. For the EAT-40 test: Z Kolmogorov–Smirnov = .902, p = .390; ABOS mother:
Z Kolmogorov–Smirnov = .719, p = .679; ABOS father: Z Kolmogorov–Smirnov = .732, p = .657.
The sample is normally distributed, so parametric tests are used.
A descriptive analysis of the main results of the questionnaires was carried out (see Table 2).
Other relevant data were that 98.39% of the mothers of the patients completed the ABOS question-
naire, compared with 87.10% of the fathers.
Considering the cutoff score equal to or greater than 21 in the ABOS questionnaire, 63.9% of
the mothers observed anorexic symptomatology in their children, compared with 36.1% of the
mothers who did not make this observation. As for the fathers, 52.7% did appreciate the ED symp-
toms, while 47.3% did not. The average of both parents exceeds the cutoff point by 1–3 points
(ABOS mother: M = 24.52, SD = 9.64; ABOS father: M = 22.69, SD = 8.93). Regarding the cutoff
point for EAT-40, a score equal to or greater than 30, 59.7% exceeded the cutoff point, while 40.3%
did not. The mean of the scores exceeds the cutoff point by 12 points (M = 42.37, SD = 25.79).
To respond to our first research objective, Pearson’s correlations were analyzed between EAT-
40 scores completed by adolescents with AN and the ABOS answered by parents. The results, as
shown in Table 3, evidence that there are no significant correlations between the scores of the EAT-
40 and the ABOS completed by mothers (R = .214, p = .098) or fathers (R = .151, p = .276). However,
there are positive correlations in the scores of the ABOS between both parents (R = .842, p < .05).
To test the second objective of the investigation, we first performed a chi-square test based on
whether the fathers and mothers exceeded the cutoff point in the ABOS. The results are
χ2(32) = 58.832, p = .003. There are statistically significant differences between both; the percent-
ages are different between the fathers and mothers. Student’s t test for one sample was conducted
with ABOS scores according to mothers and fathers. The results indicate that there are significant
differences between the two with p < .01. As shown in Table 4, mothers obtain higher scores
(M = 24.52, SD = 9.64) than fathers (M = 22.69, SD = 8.93).
Laporta-Herrero and Latorre 11

Table 2. Descriptive statistics of EAT-40 and ABOS questionnaire results.

N Minimum Maximum Media SD

EAT-40 62 3 88 42.37 25.787
ABOS mother 61 6 42 24.52 9.636
ABOS father 54 8 44 22.69 8.929

EAT: Eating Attitude Test; ABOS: Anorectic Behavior Observation Scale; SD: standard deviation.

Table 3. Correlations between EAT-40 and ABOS scores.

EAT-40 ABOS mother ABOS father

EAT-40 Pearson’s correlation 1 .214 .151
Sig. (bilateral) .098 .276
N 62 61 54
ABOS Pearson’s correlation .214 1 .842a
mother Sig. (bilateral) .098 .000
N 61 61 53
ABOS Pearson’s correlation .151 .842a 1
father Sig. (bilateral) .276 .000
N 54 53 54

EAT: Eating Attitude Test; ABOS: Anorectic Behavior Observation Scale.

aThe correlation is significant at .05 level (bilateral).

Table 4. Descriptive statistics of the ABOS scores according to mothers and fathers and AN subtypes.

N Media SD Average error of the average

ABOS mother 61 24.52 9.636 1.234
Restrictive anorexia nervosa 43 24.95 9.429 1.438
Binge-purge subtype anorexia nervosa 18 23.50 10.320 2.432
ABOS father 54 22.69 8.929 1.215
Restrictive anorexia nervosa 39 23.00 8.460 1.355
Binge-purge subtype anorexia nervosa 15 21.87 10.322 2.665

ABOS: Anorectic Behavior Observation Scale; AN: anorexia nervosa; SD: standard deviation.

To respond to the ultimate objective of the investigation, Student’s t for independent samples
was performed in order to know whether there were differences between patients diagnosed with
AN-R and AN-P, regarding the observation of symptoms by their mothers or fathers. The results
evidence that, assuming equal variances, there are no significant differences between the AN sub-
types both in the observation of symptoms by mothers (t = .534, p = .595) and fathers (t = .414,
p = .680). See Table 4, which shows the main statistics of this test.

Discussion
The first objective in this study was to determine whether the perception of parents about anorexic
symptomatology correlated with the symptomatology reported by adolescents diagnosed with AN.
The results indicate that this agreement does not happen taking the sample as a whole; that is,
12 Clinical Child Psychology and Psychiatry 25(1)

higher scores in eating symptomatology reported by adolescents with AN do not imply that parents
detect greater anorexic behavior. This result is in line with the research of Couturier et al. (2007)
but is in contrast to the study by Mariano et al. (2013). Taking into account that the EAT-40 is a
screening test, it is striking that almost half of the patients diagnosed with AN do not report enough
food symptoms to exceed the cutoff point of the test. In fact, all the patients should have exceeded
the cutoff point, since they all have AN diagnosed by specialists. On the other hand, a large propor-
tion of the parents do not detect the anorexic symptoms of their children; the mean of the score
being slightly higher than the cutoff point (1–3 points). This could be explained by the tendency to
minimization and denial of symptoms by adolescents suffering from AN as shown in the study of
Starzomska and Tadeusiewicz (2016), as well as the propensity to concealment of eating pathol-
ogy, which makes it considerably difficult for parents to detect the first signals of alarm and be
aware of the severity of the disorder.
The second objective was to examine possible discrepancies between parents regarding the
observation of anorexic behavior in their children. Although among them, they obtain a significant
positive correlation in their scores, that is, the greater observation of anorexic behavior in their
child by one parent implies a higher score in the other; differences are observed between the two.
Mothers see more eating symptoms than fathers. This result confirms our starting hypothesis.
Although there are no previous studies that compare the perception between fathers and mothers in
ED, this result would support previous studies that conclude that mothers are better at perceiving
the internalizing symptoms of their children (Grietens et al., 2004; Treutler & Epkins, 2003), tak-
ing into account our perspective of considering AN as an internalizing disorder due to the special
conditions already mentioned. A possible explanation of this fact could be that, despite the progress
that is being made in today’s society to promote greater reconciliation in work with family life in
the female sector, women still assume the major role in bringing up their children and spend the
most time with them, and therefore can better detect the changes that their children suffer.
The third and final objective was to analyze whether there were differences between adolescents
diagnosed with AN-R and AN-P with regard to the observation of anorexic behavior by their par-
ents. The results show that this difference does not exist; that is, binges and/or purging behaviors
do not make anorexic behavior more detectable by parents. This is contrary to our predictions,
because although previous studies compared AN with BN rather than subtypes of AN, we expected
that parents would perceive binges and/or purging behaviors of their children less, as Couturier
et al. (2007) had concluded. This result must be taken with great caution since the ABOS question-
naire focuses mainly on the observation of restrictive behavior and there is only a single item that
refers to self-induced vomiting and none referring to binge eating.
This study provides a novel way to compare the observation done by parents of the eating
behavior in the subtypes of AN in a clinical sample, since we have not found any current study that
investigates this aspect. On the other hand, we have been able to examine the differences in percep-
tion between fathers and mothers that had already been detected in other mental disorders but not
in ED. It must be borne in mind that the ability of an informant to provide meaningful information
about a mental disorder can be influenced by several factors such as the environment or the implicit
characteristics of the parent and the subject (Wingenfeld, 2002). In the case of parents, they may
not report their children’s problems to avoid being stigmatized or to conceal a possible intra-family
conflict (Grills & Ollendick, 2002). It can also be influenced by the parent’s own psychopathology
(Kelley et al., 2017) that they themselves have suffered or are currently suffering from ED. In the
case of adolescents, factors such as age, type of problem, and demands of the assessment setting
are significant aspects to be considered by the clinician (Smith, 2007). All these factors can influ-
ence the degree of agreement between the informants and can be decisive for the clinician to take
an informant or another more into account.
Laporta-Herrero and Latorre 13

Nevertheless, this study has a number of limitations that should be considered. The sample has
not been randomly selected; this study is not an experimental one, and the relationships between
the variables could be affected by the effect of some uncontrolled variables. It is important to note
that we have used two different self-report measures to compare the results of parents and children.
We also note that EAT-40 evaluates the frequency of a behavior, while ABOS indicates the pres-
ence/absence of a behavior, which could bias the results. Likewise, self-reported measures have
been used, so there is reliance on the sincerity of the participants in their answers. In addition,
negation and minimization of the symptomatology are frequent in AN and this affects the psycho-
metric results (Vitousek, Daly, & Heiser, 1991).
This study highlights the importance of conducting psychoeducational programs with parents
on the symptoms of AN, in order to include them in the initial assessment of their adolescent chil-
dren and in the diagnosis in the first phases of AN, because the more informed they are about the
disease, the more reliable will be the diagnosis and prognosis established (Nicholls & Yi, 2012). In
addition, the intervention of parents in the early stages of the disease will also be important.
Mansson, Parling, and Swenne (2016) found that the parents’ ability to manage ED maintaining
factors at the very start of treatment is a predictor for the short-term outcome in adolescents with
restrictive symptoms. Among the implications for clinical practice applied to the study is the need
to provide information, through media, health center, or school, regarding the first signals of alarm
and symptomatology of AN, in order for parents to detect and take appropriate measures to avoid
a chronic course of the disorder and receive adequate treatment for their children.
In conclusion, the evaluation of AN in adolescence is complicated, taking into account the ten-
dency to minimize and deny the symptoms by adolescents and the difficulty of parents to detect the
main symptoms. It seems that there are differences between parents in perceiving anorexic symp-
tomatology of their children, wherein mothers detect better than fathers.

Declaration of conflicting interests

The author(s) declared no potential conflicts of interest with respect to the research, authorship, and/or publi-
cation of this article.

Funding
The author(s) received no financial support for the research, authorship, and/or publication of this article.

ORCID iD
Isabel Laporta-Herrero https://orcid.org/0000-0002-9689-6045

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Author biographies
Isabel Laporta-Herrero is a Researcher in eating disorders. She is working as a Clinical Psychologist in a
public mental health center in Navarra (Spain).
Patricia Latorre-Forcén is a Researcher in psychosomatic medicine. She is working as a Psychiatrist in a
public psychiatry ward and preparing her doctoral thesis in the University of Zaragoza in Spain.