CALIFORNIA STATE UNIVERSITY, NORTHRIDGE
DEVELOPMENT OF AN ORIGINAL SCRIPT AND THE USE OF EDUCATIONAL
THEATER TO INCREASE EATING DISORDER AWARENESS AMONG ADOLESCENTS
A graduate project submitted in partial fulfillment of the requirements for the degree of Master of Science in Family and Consumer Sciences
by
Paige Handler
May 2018
The graduate project of Paige Handler is approved:
Scott Williams, PhD., LMFT Date
Doug Kaback, MFA Date
Annette Besnilian, Ed.D., MPH, RDN, Chair Date
California State University, Northridge
ii DEDICATION
This graduate project is dedicated to:
My parents, Deanna and Eugene Handler who have supported me through each and every endeavor I have chosen to embark upon. I could not and would not be the person I am today without your unconditional love, support and steadfast encouragement. And when life sometimes gets a little overwhelming, I will always “give it one last push.” Wishing you were still here to see the completion of this journey, Mom. You are truly missed.
My husband Jose, who has taken care of me through every moment of this crazy process.
Thank you for making my breakfast on those tough days and reminding me to breathe in and out.
All those involved in its creation. Your commitment and support helped to make this project come to life. Thank you.
Lastly, my son Henry, I have done all of this for you, my little love.
iii ACKNOWLEDGMENTS
I would like to thank my committee members who supported my efforts in writing this graduate project.
To my chair, Dr. Annette Besnilian, who was a huge support during my dietetic internship and education at CSU, Northridge. Without your vision, support, and guidance, this project would still be just an idea. Thank you for instilling the confidence in me to continue to move forward.
To Professor Douglas Kaback, whose passion for theater made all those involved believe that we could actually pull this off.
To Dr. Scott Williams, your class was my first introduction to CSUN. It is only fitting that you should be present at the completion of this journey. Thank you.
Additionally, this project, funded by an interdisciplinary grant from the CSUN Office of
Community Engagement and Marilyn Magaram Center, has been a collaboration between the
MMC, the CSUN Theater Department and the Institute of Community Health and Wellbeing’s
Neighborhood Partners in Action and honors the memory of Professors Christine H. and Owen
Smith, whose endowment was gifted to both departments.
I would like to thank the team that created the script and provided insightful feedback:
Danielle Trafficanda, Shayla Tharp, Melanie Besnilian, Daniel Salas, Haley White, Chloe
Rodriguez, and Demitria Kupershmidt. I would also like to thank Kari Hayter for volunteering to direct this project and Dr. Plunkett for your expertise on data collection and analysis. Lastly, I would like to thank all those who shared their stories about their experiences with eating disorders: Darryl, Whitney, Amber, Ryan, Shayla, Mellissa, Sharon, and Kimberly. The road to recovery is complicated, and persistence in maintaining health and self-care is a challenge. I
iv hope that this project can impart your experiences to the generations that follow and provide a way to support and connect.
v TABLE OF CONTENTS
Signature Page ii Dedication iii Acknowledgments iv Table of Contents vi Abstract vii
CHAPTER I – INTRODUCTION 1 Statement of the Problem 3 Purpose 4 Definitions 5 Assumptions 8 Limitations 8
CHAPTER II – REVIEW OF LITERATURE 9 Prevalence Data 9 Causes and Consequences 11 Lack of Education and Awareness 14 School-based Eating Disorder Education 15 Theater-based Education 16
CHAPTER III – METHODOLOGY 21 Instruments and Procedures 21 Script Development 23 Formative Evaluation 27
CHAPTER IV – RESULTS 31 Evaluation of Questionnaire by Experts 31 Evaluation of Script by Experts 32
CHAPTER V – DISCUSSION 35 Findings and Modifications 35 Limitations 37 Implications 37 Conclusion 38
REFERENCES 40
APPENDIX A: Interview Questionnaire 48
APPENDIX B: Script Development Activities 50
APPENDIX C: Script 55
APPENDIX D: Focus Group Discussion Education Guidelines 63
vi ABSTRACT
DEVELOPMENT OF AN ORIGINAL SCRIPT AND THE USE OF EDUCATIONAL
THEATER TO INCREASE EATING DISORDER AWARENESS AMONG ADOLESCENTS
by
Paige Handler
Master of Science in
Family and Consumer Sciences
Eating disorders are complex psychiatric illnesses that can be characterized by a disturbance of eating habits or weight control behaviors that can significantly impair health and psychosocial functioning. Adolescents have been diagnosed with eating disorders (EDs) with increased frequency. According to the National Youth Risk Behavior Survey, 16.7% of adolescents in grades 9-12 utilized extreme weight control behaviors in the 30 days prior to the survey (Centers for Disease Control and Prevention (CDC), 2013). These disorders show significant comorbidity with many other DSM-IV disorders (Hudson, Hiripi, Pope, & Kessler,
2007). This is a public health concern because eating disorders have been associated with functional impairment, emotional distress, suicide attempts, and various medical complications.
The purpose of this graduate project was to develop an original script, Not Otherwise Specified, on the subject to increase eating disorder awareness and knowledge among adolescents. An original five-minute script was developed through the conducting of eight extensive interviews, recorded, and then evaluated by experts. Two experts in the field of eating disorders and two experts in the field of educational theater conducted formative evaluations to ensure the script appropriately depicted the thoughts and feelings of someone experiencing an eating disorder, the
vii appropriateness of content for adolescents, and the usefulness of the project.
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CHAPTER I
INTRODUCTION
Eating disorders are mental illnesses that can be characterized by a disturbance of eating habits or weight control behaviors that result in significant functional impairment, emotional distress, and medical problems (Rohde, Stice, & Marti, 2015). In the United
States, 20 million girls and women and 10 million boys and men suffer from a clinically significant eating disorder at some time in their lives (Wade, Keski-Rahkonen, &
Hudson, 2011). The Diagnostic and Statistical Manual of Mental Disorders, 5th ed.
(DSM-5) (American Psychiatric Association (APA), 2013), lists five subgroups of eating disorders: anorexia nervosa (AN), bulimia nervosa (BN), binge eating disorder (BED), other specified feeding or eating disorder (OSFED), previously eating disorders not otherwise specified (EDNOS), and unspecified feeding or eating disorder (UFED). It has been found, however, that use of DSM criteria may be problematic for diagnosis of children and adolescents because their clinical presentation often differs from that of older adolescents and young adults (Mahan, Escott-Stump, & Raymond, 2012 p. 492).
Despite the presence of diagnosis, onset of eating disorders generally occurs during adolescence or young adulthood and are affecting this population with increased frequency. Among females, they rank as the third most common chronic illness with an incidence of up to 5% (Society for Adolescent Medicine, 2003) and affect about one in
10 adolescent females (Swanson, Crow, Le Grange, Swendsen, & Merikangas, 2011).
Additionally, a majority of adolescents with eating disorders reported contact with a professional for emotional or behavioral problems, but only a few individuals with eating disorders actually talked to a professional about their eating or weight problems
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(Swanson et al., 2011).
Risk factors for all eating disorders involve a range of psychological, biological, social, and cultural issues (National Eating Disorders Association, (NEDA), 2018). These factors may affect individuals differently and manifest with a wide range of symptoms and perspectives (NEDA, 2018). Some contributing factors for the onset of eating disorders include genetics, history of chronic dieting or other weight control behaviors, body image dissatisfaction, weight stigma, ideal body internalization, anxiety disorders, perfectionism, and history of trauma (NEDA, 2018).
Current interventions for eating disorders include psychological counseling or psychotherapy in conjunction with both nutritional and medical monitoring (NEDA,
2018). Psychological counseling focuses on underlying conditions that have contributed to the onset of the eating disorder and current eating disorder risk factors or behaviors.
Additionally, analysis of the family context is relevant, especially for adolescents, and incorporating family therapy approaches has been beneficial (Costa, & Melnik, 2016).
Prevention programs have explored different tactics (Pearson, Goldklang, &
Striegel-Moore, 2002; Stice, Shaw & Marti, 2007; Neumark-Sztainer, Butler, & Palti,
1995). Methods such as eating disorder educational presentations, according to Stice,
Becker, and Yokum (2013), showed no reduction in eating disorder risk factors or onset of eating disorders. Tactics aimed to reduce risk factors such as thin idealization, body dissatisfaction, dieting, and low self-esteem showed some reduction in risk factors alone but no reduction in onset or behavioral symptoms (Stice, Becker & Yokum, 2013). A review by Stice, Shaw, Becker, and Rohde (2008), found the application of dissonance- theory reduced eating disorder symptoms and risk factors to be efficacious, with a 60%
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reduction in eating disorder behaviors in a three-year follow up relative to a control condition. Although different types of eating disorder prevention programs have been developed and evaluated, only 5% have produced lasting reductions in current or future eating disorder behavior (Stice et al., 2008). Educational theater has been an effective tool in increasing knowledge related to other health behaviors among adolescents
(Joronen, Rankin, & Astedt-Kurki, 2008), and some have explored using educational theater as a tool for reducing eating disorder risk factors (Mora et al., 2015; Haines,
Neumark-Sztainer, & Morris, 2008).
Various scholars have argued for intervention during early adolescence and continuing through young adulthood (Neumark-Sztainer, Wall, Larson, Eisenberg, &
Loth, 2011; Heatherton, Mahamedi, Striepe, Field, & Keel,1997; Kotler, Cohen, Davies
M, Pine, & Walsh, 2001) and could possibly be beneficial in the prevention of onset of disordered eating habits or more extreme weight control behaviors, such as eating disorders. Therefore, there is a strong need for the implementation of school-based eating disorder prevention programs to increase eating disorder awareness during early adolescence (Neumark-Sztainer, 2016; Kantha, Rani, Parameswaran, & Indira, 2016).
Statement of the Problem
Eating disorders are complex conditions that can arise from various potential causes. In the United States, 20 million girls and women and 10 million boys and men suffer from a clinically significant eating disorder at some time in their life (Wade,
Keski-Rahkonen, & Hudson, 2011). Factors that may contribute to eating disorders include both risk factors and correlating factors such as genetics or social pressures.
General eating disorder risk factors can include body dissatisfaction, internalization of
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thin-idealization, dieting, and lack of familial support (NEDA, 2016).
There is little population-based data on the prevalence of eating disorders, and rates of prevalence vary depending on the stringency of guidelines for diagnosis (Hudson et al., 2007). The lack of data for sub-threshold and partial eating disorders, such as purging disorder, are concerning because most adolescents who seek eating disorder treatment do not satisfy the criteria for DSM-IV for anorexia nervosa or bulimia nervosa
(Fairburn & Harrison, 2003; Fisher, Schneider, Burns, Symons, & Mandel, 2001; Herzog,
Hopkins, & Burns, 1993; Williamson, Gleaves, & Savin, 1992). Sub-threshold and partial eating disorders are associated with functional impairment, distress, suicide attempts, medical complications, and increased risk for current and future psychiatric and medical problems (Crow, Agras, Halmi, Mitchell, & Kraemer, 2002; Milos, Spindler, Schnyder,
& Fairburn, 2005; Stice, Marti, Spoor, Presnell, & Shaw, 2008; Striegel-Moore, Seeley,
& Lewinsohn, 2003). Thus, eating disorders are a public health concern and should be addressed as such. There have been school-based interventions utilized (Neumark-
Sztainer, 2016), but effectiveness has varied. Educational theater techniques have been successful in increasing knowledge about other health-related topics (Joronen et al.,
2008). Prevention programs utilizing techniques such as educational theater may increase eating disorder awareness.
Purpose
The purpose of this project was to develop a script to increase eating disorder awareness and knowledge in secondary school children. Adolescents are at high risk for developing eating disorders and sub-threshold eating conditions (Swanson et al., 2011), and risk factors for symptoms of eating disorders and eating disorder behaviors escalate
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during this time (Rohde, Stice & Marti, 2015). Early detection and treatment of eating disorders may prevent progression and reduce the risk of related health consequences
(Austin, Ziyadeh, Forman, Prokop, Keliher, & Jacobs, 2008). School-based eating disorder prevention programs can reach a large number of adolescents during this pivotal time in their development (Neumark-Sztainer, 2016). Educational theater has been found to be an effective prevention tool (Haines, Neumark-Sztainer & Morris, 2008).
The script developed for this project can continue to be utilized to raise eating disorder awareness, prevent eating disorder risk factors, and initiate discussions among youth.
Definitions
1. Anorexia nervosa
a. Restriction of energy intake relative to requirement, leading to a significantly
low body weight in the context of age, sex, developmental trajectory, and
physical health.
b. Intense fear of gaining weight or becoming fat, or persistent behavior that
interferes with weight gain, even though at a significantly low weight.
c. Disturbance in the way in which one's body weight or shape is experienced,
undue influence of body weight or shape on self-evaluation, or persistent lack
of recognition of the seriousness of the current low body weight (APA, 2013).
2. Bulimia nervosa
a. Recurrent episodes of binge eating.
b. Recurrent inappropriate compensatory behaviors (such as self-induced
vomiting, misuse of laxatives, fasting, or excessive exercise) to prevent
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weight gain.
c. Binge eating and inappropriate compensatory behaviors both occur, on
average, at least one time per week for three months.
d. Self-evaluation is unduly influenced by body shape and weight.
e. The disturbance does not occur exclusively during episodes of anorexia
nervosa (APA, 2013).
3. Binge eating disorder
a. Recurrent episodes of binge eating.
b. Binge eating episodes are associated with three or more of the following:
i. eating much more rapidly than normal;
ii. eating large amounts of food when not feeling physically hungry;
iii. eating until feeling uncomfortably full;
iv. eating alone because one is embarrassed by how much one is eating;
v. feeling disgusted with oneself, depressed, or very guilty after
overeating.
c. Marked distress regarding binge eating.
d. Binge eating occurs, on average, at least one time per week for three months.
e. Binge eating is not associated with the regular use of inappropriate
compensatory behavior and does not occur exclusively during the course of
bulimia nervosa or anorexia nervosa (APA, 3013).
4. Other specified feeding or eating disorder (OSFED), formerly eating disorder not
otherwise specified (EDNOS)
a. Atypical anorexia nervosa: all criteria for anorexia nervosa are met; despite
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significant weight loss, the individual's weight is within or above the normal
range
b. Bulimia nervosa of low frequency and/or limited duration.
c. Binge eating disorder of low frequency and/or limited duration.
d. Purging disorder.
e. Night eating syndrome (APA, 2013).
5. Sub-threshold eating disorder: individuals who experience all the symptoms of a
particular eating disorder, but whose levels of one or more symptoms is too low for
full DSM diagnosis.
6. Adolescence: the developmental period between puberty and the attainment of adult
status within society (Journal of Adolescence, 2018). Research into adolescence and
eating disorders generally covers 11-18 years of age (Bezance & Holliday, 2013).
7. Educational theater is the use of theatrical means to impart a lesson on a particular
topic.
8. Dissonance-based interventions encourage participants to both privately and publicly
criticize the thin-ideal through written, verbal, and behavioral exercises.
9. The Youth Risk Behavior Surveillance System (YRBSS) monitors six categories of
priority health-risk behaviors among youth and young adults, including behaviors that
contribute to unhealthy dietary behaviors. YRBSS includes a national school-based
survey conducted by the CDC and state and local school-based surveys conducted by
state and local education and health agencies.
10. Eating Disorders Awareness Test assesses awareness of the risks and maintaining
factors of eating disorders. It consists of 51 statements (e.g., "Bulimia only affects
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women," "For the average person, weight loss slows down when dieting because the
body gets used to less food") with three possible answers: "true," "false,” and
"unsure."
Assumptions
The evaluation for this educational theater project was based upon the following assumptions:
• evaluators watching the performance of the script can understand English;
• evaluators asked to complete evaluation forms can read and understand
English; and
• evaluators will answer questions on the evaluation forms honestly.
Limitations
This project will contribute to the body of work regarding eating disorder prevention programs. However, certain limitations exist.
• The script is intended for a secondary school audience.
• The script, future workshops, and evaluation materials are geared toward
individuals who understand and read English.
• The questionnaire utilized for interviews was only evaluated by two experts.
Other types of professionals may have provided different insights into the
questionnaire.
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CHAPTER II
REVIEW OF LITERATURE
This chapter provides a review of the research about eating disorders to gain a better understanding of this group of mental conditions. This research will contribute to current information about effective prevention tools. The literature review will help facilitate the development and implementation of an original script to help increase eating disorder awareness and knowledge among adolescents.
Prevalence Data on Eating Disorders in Adolescents
National Data
In the United States, 20 million girls and women and 10 million boys and men suffer from a clinically significant eating disorder at some time in their lives (Wade,
Keski-Rahkonen, & Hudson, 2011). This statistic aligns with general findings of Hudson et al. (2007), whose research examined data from the National Comorbidity Survey
Replication. This survey was administered face to face to a sample of 9,282 English- speaking U.S. adults ages 18 and older from 2001-2003 who were assessed for three primary disorders: anorexia nervosa, bulimia nervosa, and binge eating disorder.
Additionally, they looked for behaviors associated with subthreshold binge eating disorder (SBED) and any binge eating episodes that occurred at least twice per week over the course of three months. They found lifetime prevalence of anorexia nervosa, bulimia nervosa, and binge eating disorder to be 0.9%, 1.5%, 3.5%, among women, respectively, and 0.3%, 0.5% and 2.0% among men, respectively. Additionally, subthreshold binge eating disorder was found to be three times as high for men than it was for women, while any binge eating was equal among both sexes.
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According to the position paper of the Society for Adolescent Medicine (2003), eating disorders are affecting adolescents with increased frequency and rank as the third most common chronic illness in adolescent females, with an incidence of up to 5%. An adolescent supplement of the National Comorbidity Survey Replication was examined by
Swanson et al. (2011). The survey was administered to 10,123 adolescents ages 13-18 years old and found that lifetime prevalence estimates of anorexia nervosa, bulimia nervosa, and binge eating disorder were 0.3%, 0.9%, and 1.6%, respectively, and that ranges for onset for anorexia nervosa, bulimia nervosa, binge eating disorder, and subthreshold binge eating disorder were 11.2 to 13.0, 11.1 to 13.5, 11.2 to 13.5 and 10.0 to 14.3 years, respectively. They concluded that eating disorders, including sub-threshold eating conditions, are prevalent in the general adolescent population.
It is estimated that subthreshold eating disorders are 20 times more prevalent in the community than those who meet diagnostic criteria (Favaro, Ferrara, & Santonastaso,
2003). The Youth Risk Behavior Surveillance System (YRBSS) found that during the 30 days preceding the survey, 47.7% of students were trying to lose weight (Centers for
Disease Control and Prevention, 2014), 40.7% of students nationwide had restricted calories to keep from gaining weight (CDC, 2006), 13.0% had gone without eating for more than 24 hours, 4.4% had vomited or taken laxatives, 5.0% had taken diet pills, powders, or liquids without a doctor’s advice (CDC, 2014), and 60.0% had exercised to control weight (CDC, 2006). The CDC stopped tracking weight control behaviors among adolescents in 2013. The lack of data for sub-threshold eating disorders is of concern because most adolescents who seek eating disorder treatment do not satisfy DSM criteria
(Fairburn & Harrison, 2003; Fisher, Schneider, Burns, Symons, & Mandel, 2001; Herzog,
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Hopkins, & Burns, 1993; Williamson, Gleaves, & Savin, 1992), and subthreshold eating disorders can be associated with functional impairment, distress, suicide attempts, medical complications, and increased risk for current and future psychiatric and medical problems (Crow, Agras, Halmi, Mitchell, & Kraemer, 2002; Milos, Spindler, Schnyder,
& Fairburn, 2005; Stice, Marti, Spoor, Presnell, & Shaw, 2008; Striegel-Moore, Seeley,
& Lewinsohn, 2003).
Prevalence of Eating Disorders in Los Angeles
According to the YRBSS local surveys of Los Angeles adolescents, grades 9-12,
53.3 % of students were trying to lose weight (2013), 42.9% restricted calories (2005),
10.6% went without eating for more than 24 hours (2013), 5.4% vomited or took laxatives (2013), 5.5% took diet pills, powders, or liquids (2013), and 66.6% exercised to lose weight or to keep from gaining weight (2005). The number of students trying to lose weight in Los Angeles was above the national average for large urban areas (median
44.6%) and ranked as the highest among cities surveyed (2013). Additionally, the
YRBSS (2005) showed that Los Angeles had the highest number of students who engaged in restricting calories (median 35.9%) and who exercised (median 58.7%) to lose or prevent weight gain.
Causes and Consequences of Eating Disorders
Problem
According to Neumark-Sztainer et al. (2011), the majority of research indicates that disordered eating behaviors during early adolescence are predictive of future eating habits, including the potential for behaviors to lead to eating disorders in later adolescence or young adulthood. In an effort to expand upon existing literature, they
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examined the prevalence of dieting and disordered eating behaviors, including unhealthy weight control behaviors, extreme weight control behaviors, and binge eating with loss of control in a 10-year longitudinal study called Project EAT-III (Eating and Activity in
Teens and Young Adults). The study tracked 1,030 young men and 1,257 young women over 10 years. Participants were placed into two cohorts, 29.9% in the younger cohort with a mean age of 12.8±0.7 at baseline and 70.1% in the older cohort with a mean age of
15.9±0.8 at baseline. Results indicated that disordered eating, including binge eating, tended to continue into young adulthood, particularly among the older cohort for both sexes. Additionally, both girls and boys from each cohort who dieted or used unhealthy weight control behaviors in adolescence were at significantly greater risk of these behaviors continuing into young adulthood. Results also indicated that extreme weight control behaviors during middle adolescence predicted greater risk of these behaviors in young adulthood, with diet pill use more than tripling. Rohde et al. (2015) found that the greatest number of risk factors for the future onset of EDs present at 14 years of age.
These findings highlight the need for early and ongoing prevention interventions.
Contributing Factors
The pathogenesis of eating disorders is multifactorial with psychological, social, and biological elements. Factors that contribute to eating disorders include both risk factors such as body dissatisfaction, internalization of thin-idealization, dieting, and lack of familial support (NEDA, 2016) and other correlating factors such as genetics and social pressures.
Genetic factors are responsible for the vulnerability to disorders and can been seen in both epidemiological studies and molecular genetic studies that have discovered
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variants of genes that may influence ED risk (Monteleone & Maj, 2008). Several studies have reported a significantly higher frequency of anorexia nervosa or bulimia nervosa in relatives of participants with an eating disorder compared with relatives of healthy controls (Gorwood, Kipman, & Foulon, 2003), with an average of 2.69% lifetime risk of anorexia nervosa in first degree relatives, compared with 0.18% in relatives of healthy controls. This suggests a familial component (Gorwood et al., 2003) and that specific genes can predispose individuals to eating disorders.
Studies of twins have shown a higher concordance rate of anorexia nervosa or bulimia nervosa in monozygotic (MZ) twins than in dizygotic (DZ) twins (Monteleone &
Maj, 2008), also implicating genetic factors. Bulik, Sullivan, Tozzi, Lichtenstein, and
Pedersen (2008) conducted a large twin study by screening all living twins in the Swedish
Twin Register (n = 31,406) born between 1935 and 1958, and the heritability of anorexia nervosa was estimated to be 56%, with the remaining variance attributable to shared environment (5%) and unique environment (38%).
Body dissatisfaction is a major risk factor for the onset of eating disorders. Data collected from a prospective study of 496 adolescent girls who completed diagnostic interviews and surveys annually for eight years showed that body dissatisfaction was a predictor of eating disorder onset. Adolescents in the top 24% of body dissatisfaction had a four-fold increase in eating disorder behavior. Additionally, among those with high body dissatisfaction, depressive symptoms amplified onset (43% vs. 15%), suggesting an interaction between these two risk factors (Stice, Marti, & Durant, 2011).
Consequences
Anorexia and bulimia nervosa are associated with comorbid medical conditions,
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including complications of the gastrointestinal, cardiovascular, and endocrine systems and bone disorders such as osteoporosis. Disordered weight control behaviors such as purging and abuse of laxatives can be associated with a range of negative health outcomes such as esophagitis, gastric rupture, and impairment of digestive functioning
(NEDA, 2018). Additionally, compared with the general population, people with anorexia or bulimia nervosa are at increased risk of suicide (Pompili, Girardi, Tatarelli,
Ruberto, & Tatarelli, 2006). Swanson et al. (2011) found that each eating disorder subtype was associated with significantly elevated levels of suicidal thoughts among adolescents. Bulimia nervosa and subthreshold anorexia nervosa were associated with suicide plans, and bulimia nervosa and binge eating disorder were associated with suicide attempts (Swanson et al., 2011).
Lack of Education and Awareness
Research about knowledge and awareness on eating disorders among adolescents is limited, and few have sought to investigate the implications of knowledge on behavior
(Czepczor, Koscicka, & Brytek-Matera (2016). Czepczor et al. (2016) sought to add to the body of literature by evaluating knowledge about eating disorders in young women and men. Their sample included 34 females and 32 males aged 19-21. All participants were given the Eating Disorders Awareness Test to assess their knowledge. Results found that knowledge of eating disorders was significantly higher in women than in men and that most women (72.2%) derived their knowledge from science books, while 27.3% derived knowledge from media, including the Internet and television. This is of concern because the reliability and credibility of websites are often unsatisfactory. Additionally, the majority (83%) of participants referred to anorexia nervosa as dangerous and
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potentially fatal, but when asked to identify risk factors for eating disorders, only 11% of participants agreed with the statement that weight loss was indeed a risk factor and 9%
"strongly agreed" that people suffering from an eating disorder had a distorted perception of their own body. Similarly, in a study by Godala, Karasinska, Trafalska, Kolmaga, and
Szatko (2012), 90% of interviewees declared they knew the concept of anorexia nervosa, but verification in later research showed that only 17% of them had appropriate knowledge of the disorder (Czepczor et al., 2016).
Due to the increasing prevalence in eating disorders, Kantha, Rani,
Parameswaran, and Indira (2016) sought to assess knowledge regarding eating disorders among adolescent girls (N=100) between the ages of 15-20 years old. Findings of the study revealed that the majority of participants (87%) had inadequate knowledge regarding eating disorders. The researchers concluded that there is a strong need to conduct health education curricula to improve knowledge among this population.
School-based Eating Disorder Education
Knowledge of basic nutrition, weight issues, and eating disorders is critical for school personnel who are in the position to teach eating disorder curricula. Incorrect knowledge and inappropriate perceptions about weight and body image may be transferred from teacher to student (Thompson, Smith, Hunt, & Sharp, 2006). Jones,
Brener, and McManus (2004) reported that only 32.1% of teachers in middle and high schools had participated in staff development programs that enhanced knowledge of dietary behaviors. Thompson et al. (2006) sought to investigate educators' perceptions, beliefs, and practices in the teaching of eating disorder prevention by providing surveys to health educators via mail to 600 different high schools across the United States.
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Researchers received a 56% response rate to the survey. Analysis of data showed that
88% of respondents agreed that health educators should provide eating disorder education and 75% indicated that they had provided instruction on the topic within the last year.
However, 63% reported using simple instruction only. According to Jones et al. (2004), teachers who receive additional education in a specific area are more likely to teach four or more hours on that topic. It is therefore important that personnel receive proper training about eating disorders to increase eating disorder knowledge among students.
In an effort to increase the recognition of eating disorders in the Netherlands, secondary schools have started providing lessons on both risk factors and characteristics of eating disorders. An evaluation of 234 lessons presented to 3,879 secondary students
(aged 11-17) between 2000 and 2006 was conducted by Noordenbos and Van Duyn
(2009). Lessons were conducted by recovered eating disorder patients who had received special education on risk factors, characteristics, and various consequences of eating disorders. Instruction additionally included educators sharing their own experiences in treatment and recovery. Results from post-education questionnaires (no pretest was given) showed that 17% of students recognized eating disorder symptoms in others and
9% recognized symptoms in themselves. Of those that recognized symptoms in themselves 33% did not want to talk about their eating disorder symptoms at all.
Additionally, 37% of students wanted additional information about characteristics of eating disorders and possibilities of help and treatment for others. The fact that such a large proportion of students requested additional information suggests that the education surrounding eating disorders is limited.
Theater-based Education
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Various studies (Joronen, Rankin, & Astedt-Kurki, 2008; Stice, Shaw & Marti,
2007; Tobler et al., 2000) have concluded that interactive methods of education are more effective than traditional didactic methods to increase knowledge, create community discussion, and increase awareness. Theater and role-playing methods have been commonly used for health promotion, but evidence of their effectiveness has been limited
(Joronen, Rankin, & Astedt-Kurki, 2008).
Harvey, Stuart, and Swan (2000) investigated the effectiveness of a drama intervention among 699 students from 14 secondary schools in KwaZulu, South Africa, in a randomized controlled trial aimed at increasing knowledge, attitudes, and behavior related to HIV/AIDS and sex. Seven schools were given education via the performance of a play followed by workshop discussions, while seven other schools received education via an informational booklet. Results showed that students who were exposed to the performance and subsequent workshop had an average increase in HIV/AIDS knowledge of 10.8% versus a 1.8% average increase among those receiving written information alone. Additionally, in schools receiving the drama intervention, sexually active students reported an increase in condom use.
A similar study was conducted on the effectiveness of Kaiser Permanente’s
Educational Theater Program, the performance curricula of which was geared toward obesity prevention. Pretest and posttest surveys looked at knowledge gains and retention of healthful eating and active living behaviors in 2,915 elementary school children.
Results showed that the percentage of children who answered questions correctly increased from 17% to 63% immediately after performances and that posttest assessment three weeks later showed only a slight decline, with 54% retention (Cheadle et al., 2012).
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Other researchers have had similar results. Perry, Zauner, Oakes, Taylor, and
Bishop (2002) sought to change food-related knowledge and food choices concerning fruits and vegetables among 4093 students, grades 1-6. An actor performed a 45-minute play titled All’s Well that Eats Well to students in 20 different schools across
Minneapolis. Performances were followed with both classroom and home activities.
Investigators administered pretests and posttests to all students in two randomly assigned groups. Their findings showed no significant differences between the groups at pretest.
Pre-post significant differences occurred in food-related knowledge and food choices
(Perry et al., 2002).
Gallagher (2009) utilized educational theater as an intervention that encouraged educators to challenge assumptions regarding poverty. A play was presented in 15 elementary schools across different regions of Ontario over a two-year period. The objective of the play was to explore assumptions about poverty and its impact on students, as well as how educators can work together mitigate the effects of poverty on academic achievement. Educators and actors led subsequent workshops with students on the material. Results showed that the performance acted as a catalyst in opening up a dialogue about the subject among both educators and their students.
Theater as a Prevention Tool for Eating Disorders
Mora et al. (2015) evaluated the long-term effects of two school-based prevention programs on disturbed eating attitudes, aesthetic ideal internalization, and other eating disorder risk factors among 200 adolescents aged 12-15. Prevention programs were based on 1) philosophies of media literacy education and 2) dramatic arts (Theater Alive).
Results showed that students in both experimental groups had significantly higher self-
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esteem scores over time compared to the control group. However, they found no difference in body dissatisfaction or disordered eating attitudes. Limitations of this study, including lack of student participation in discussions of the content of the play, indicate that methodology may have played a role in these results. Haines et al. (2006) found that participation in the development and performance of a play around weight-related issues improved body satisfaction and increased resilience to comments from others.
Other school-based prevention programs (McVey, Tweed & Blackmore, 2006) have sought to reduce risk factors for eating disorders. McVey et al., (2006) created a program titled "Healthy Schools—Healthy Kids" in which they examined its influence on improving body satisfaction and size acceptance and reducing the internalization of media ideals, weight-based teasing, and disordered eating. The comprehensive program surveyed 982 male and female sixth- and seventh-grade students at baseline, and 84% of the students repeated the surveys immediately after the conclusion of the eight-month intervention and 71% completed follow-up surveys. The "Healthy Schools—Healthy
Kids" program included multiple components such as researcher-led workshops, teacher- led curriculum, peer support groups, and public service announcements. The presentation of a 50-minute play, performed by local high school students, and subsequent discussions were only two aspects of this comprehensive program. Results showed that participation in the program had a positive influence in reducing the internalization of media ideals among both male and female students and in reducing disordered eating behaviors in female students.
Conclusion
Research has found that eating disorder prevalence among adolescents in the
19
United States, and specifically in Los Angeles, is a continuing health concern (CDC,
2014). Although the number of those affected may seem low, eating disorders contribute to an array of both physical and mental health issues that may result in death or suicide.
School-based programs reach a large, captive audience of young people at a critical stage of development (Neumark-Sztainer, 2016). Current school-based education in the United
States is limited, with 63% of educators reporting only simple instruction (Thompson et al., 2006). School-based education generally takes a didactic approach, but various studies have indicated that interactive methods may be more beneficial to increase knowledge and awareness and generate discussion (Thompson et al., 2006). Educational theater is a useful tool for engaging students around the subject. The review of literature in this chapter highlighted a research gap. The number of eating disorder prevention programs utilizing educational theater as an intervention method has been limited, and those that have used theatrical works have presented them in conjunction with other components.
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CHAPTER III
METHODOLOGY
The purpose of this project was to create a script to be used as an educational tool to increase eating disorder awareness among adolescents. First, a questionnaire was created to be used for interviews. Next, the script was developed based on identifiable themes found among the interviews. Then a live performance of the script was recorded.
Finally, two experts in the field of eating disorders and two experts in the field of educational theater conducted formative evaluation.
Instruments and Procedures
The instruments used included (1) an interview questionnaire with questions pertaining to personal experience with eating disorders (see Appendix A); (2) Not
Otherwise Specified script (see Appendix C); (3) video performance of script; and (4) evaluations from two experts in the field of eating disorders and two experts in the field of educational theater.
Interview Participant Procedures
Selection criteria to be interviewed included previous treatment or experience with an eating disorder. Interviewees were recruited via email outreach to Joint
Advocates on Disordered Eating (JADE) on CSUN campus, an eating disorder peer education program, colleagues in the dietetics community, and through personal connections to those with a history of eating disorders. In all, eight participants were selected. All interviewees participated voluntarily and were not compensated for their participation.
A team consisting of CSUN theater faculty, theater and dance students, and
21
nutrition and dietetic students were present during the interviews over a two-day period.
All interviews were led by the project team leader. Two of the interviews took place face to face, while all other interviews were conducted over the phone. Seven females and one male were interviewed for this project. All interviews were recorded and subsequently transcribed or summarized. All interviewees were asked the following questions.
Interviewee Questionnaire
1. Current age; age of start of eating disorder (ED)?
2. What ED were you first diagnosed with? Did your diagnosis ever change?
3. What do you feel originally triggered to your ED?
4. What need did the ED fulfill?
5. What messages did you receive about weight/ body image growing up?
6. What were some of the first signs/symptoms of the ED?
7. What are your personal/specific triggers?
8. Is/was compulsive exercise a behavior that you exhibited?
9. Do/did you ever use laxatives?
10. How many hours of the day do/did you spend thinking about food?
11. If you weren’t thinking about food/weight, what do you imagine you would be feeling?
12. Who knows about your ED?
13. What type of support did your family/friends provide? Or did they?
14. If a friend suspected your ED, how would you like them to approach you to provide help?
15. If you were an acquaintance of someone with an ED, how would you approach them
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to provide help?
16. What do you think are the most misunderstood things about ED?
17. What is scary about recovery?
18. What type of treatment did you seek? or receive?
19. Are you currently still receiving treatment?
20. If you can think back to before you decided to seek treatment, what kinds of things might have been helpful to push you in that direction?
Script Development
This project included the development of an original five-minute script that was created collectively by California State University, Northridge (CSUN) students and faculty. The script was based on information gathered from eight interviews and subsequent development workshops with production team members.
Over the course of two days, the team leader conducted eight interviews with individuals who had a history of an eating disorder. The primary purpose of the interviews was to provide an oral history of the experience of having an eating disorder, as well as to provide personal reflection on their experiences that led them to seek treatment and if other tactics or approaches would have been beneficial.
Each interview began with an introduction of the purpose of the project and what we hoped to accomplish through the development of the script. The interview consisted of 20 questions that guided interviewees to speak about their experiences. All interviews were recorded and transcribed. Then production team members identified common themes among interviewees: (1) perfectionism or pressure, (2) loneliness, (3) the eating disorder gave them a sense of power or control, and (4) the eating disorder provided a
23
high or comfort. Based on these themes, theater and nutrition students worked together to formulate the text for the script titled Not Otherwise Specified by using theater-based activities that included imagery, improvisations, and writing. After engaging in development activities led by theater department faculty, the production team gave the script a more formalized structure. The team then collectively provided feedback, editing and rewriting during four rehearsal sessions with the guidance of an additional CSUN theater faculty member with a specialization in directing. The script was finalized in
September 2016, and performed and video recorded for an audience attending the
Marilyn Magaram Center’s 25th anniversary celebration. Audience members included
CSUN donors, current and former faculty and staff, and current CSUN students.
Script Development Activities
A CSUN theater faculty member and expert in educational theater led three workshop sessions. Team members met on CSUN campus in August 2016 and participated in theater-based activities that were developed by the educational theater expert. Activities included Write Around, Accordion Poems, Silent Dialogue, Image
Sculpting, and Graffiti Wall (see Appendix B for additional samples of writings and photos).
Write Around. This activity focused on scene development. Team members were instructed to write a line of dialogue in the scene and then pass the paper to the person next to them. This process continued, writing one line and passing the paper back and forth until the scene was complete. This activity directly followed an improvisational exercise in which team members were given a set of circumstances as a guide. The following is a sample of scene development from this exercise that became part of the
24
final script.
Scene 1: Fast Food Restaurant
PH: What are you going to get?
DK: I am so hungry. I can eat anything! Maybe a McDouble?
PH: Right?! That sounds good. I never know what to get here. What do you want?
DT: Ummm. I don’t know. Nothing sounds good. Is there anywhere else we can
go?
PH: There isn’t any other place to eat around here and I’m starveballs! I think
I’m just going to get a cheeseburger and fries.
DK: Ohh. That sounds good! (Looks to DT) What about a salad?
DT: (Looking dazed and confused) Uhhh. Yeah, but the salads have so much stuff
on them. You guys order. I’ll figure it out or get something later. I’m not that
hungry. Really.
PH: GURRLL!!
DK: How are you not hungry?! We haven’t eaten since 1 and it’s 7!
DT: (Shrugs shoulders)
PH: Well, I’m going to order. I’ll order you a salad. What salad do you want?
DT: Order whatever you want. The salad is fine.
PH: Which one?
DT: I don’t care. I just want to get out of here.
DK: We will leave after we eat. We definitely need to eat something. Stop being
so complicated!
DT: Sorry. I’m not trying to be complicated. I told you guys to order and not to
25
worry about me. I told you I’m not hungry.
PH: Fine. I’m getting you a salad.
DT: Fine.
Accordion Poem. This activity created collective poems prompted by a line of dialogue created in the Write Around activity. Team members could only see one line previous to theirs by folding the paper, like an accordion, and were instructed to continue writing the poem line by line by passing the paper between all participants. The following is a sample of a poem in which lines became dialogue in the final script.
I’m more powerful than you. I don’t have to rely on food.
I am strong like an ultimate fighting champion.
I am stronger than you.
I prevail. I conquer. I am undaunted.
But yet I’m still haunted.
Haunted by my ghost. By the skeleton of a women who once stood before me.
Who am I anymore?
What do I care about anymore?
I don’t care about myself.
I care about them. The voices, the thoughts, the stares.
But they are monsters.
I am a monster.
Graffiti Wall. In this activity, the identified theme words " loneliness,"
"perfection," "pressure," "control" and "high" were written in the center of a large poster paper, and team members were encouraged to brainstorm and expand upon these words
26
by using free association both individually and collectively. This exercise assists in character development (see Appendix B for images of Graffiti Wall).
Image Sculpting. In this activity, theme words and generated thoughts from
Graffiti Wall served as the basis of the creation of tableaux or still images by bringing the emotional into the physical realm. This process created “sculpted” images that were formed in groups. Afterwards, feelings and thoughts regarding being in and viewing the images and shapes were verbally expressed and served as a jumping-off point for continued scene development.
Formative Evaluation
Formative Evaluation of the Interview Questionnaire by Eating Disorder Experts
After the questionnaire was developed, it was evaluated for content and appropriateness by two experts in the field of eating disorders. The questionnaire was modified based on their comments.
Description of the Experts
Expert 1 is a registered dietitian who holds a master’s degree in nutrition and dietetics from California State University, Northridge. She has worked in both private practice and as the outpatient dietary supervisor at an intensive outpatient/partial hospitalization eating disorder program. This reviewer has worked with the eating disorder population for over eight years. Expert 2 is a registered dietitian who holds a master’s degree in public health from California State University, Northridge and has worked in private practice with eating disorder clients for five years.
Expert Evaluation Procedures
Dietetic experts were chosen based on their specialization with eating disorders
27
and their willingness to participate in the project. The purposes of the project and of the questionnaire were explained to each participant over the phone. They were sent the questionnaire via email and asked to provide feedback at their leisure. Their responses were timely, and they did not receive any compensation for their contributions. After the questionnaire was edited, it was used to conduct interviews for script development.
Formative Evaluation on the Script by Experts
After the script was developed, performed and recorded, it was evaluated for content and appropriateness by four experts. Two of the experts specialize in the field of eating disorders, and two experts specialize in the field of educational theater. Comments for modifications were noted, and changes will be implemented in future revisions of the script.
Expert Evaluation Measure
The experts were asked to assess the script's content, appropriateness, and usefulness. Specifically, the experts were asked to answer the following questions: (1) As a professional in your field, can you please discuss the messages, if any, that you received from watching this video? (2) Do you think the content is appropriate for adolescents who may or may not have an eating disorder? Please explain; and (3) Would you use this video to facilitate open group discussions about eating disorders? Why or why not?
Additionally, experts were encouraged to leave additional feedback or comments.
Description of the Experts
Expert 1 is a registered dietitian who holds a master’s degree in nutrition and dietetics from California State University, Northridge. She has worked in both private practice and as the outpatient dietary supervisor at an intensive outpatient/partial
28
hospitalization eating disorder program. This reviewer has worked with the eating disorder population for over eight years.
Expert 2 is a licensed marriage and family therapist, a certified trauma resiliency model practitioner and a certified eating disorder specialist. She currently works in private practice and has worked with the eating disorder population for over five years.
Expert 3 is a founding member and the co-artistic director of an independent theater company, the primary interests of which lay in the intersection of theater and education, Expert 3 has served as a guest director and teacher at Vassar College, Harvard and PACE University.
Expert 4 holds a master’s degree in educational theater and is the resident teaching artist of a major theatrical venue. In this role, Expert 4 focuses on engagement, learning, and connection through talk back sessions with students. Additionally, this expert has served as an associate director of education for multiple theater companies and is concurrently a professor at multiple universities in California and artist-in-residence in both New York and Los Angeles public schools.
Expert Evaluation Procedures for the Script
Four experts were chosen as evaluators of the script. The two eating disorder experts and one educational theater expert were chosen by the lead project member, and the fourth expert was chosen by university theater faculty. Each expert was approached individually by the lead member of the project. Each expert was informed about the purposes of the project and of their evaluations. Experts were emailed a link to view the video along with evaluation questions. Additionally, reviewers were provided the opportunity to give open-ended comments about the script. Experts assessed the content,
29
appropriateness, and usefulness of the project.
30
CHAPTER IV
RESULTS
The purpose of this project was to develop a script aimed at educating students on eating disorders, with the ultimate objective of helping prevent eating disorders through increased knowledge and awareness. Through the collection of feedback from formative evaluations by experts in the fields of eating disorders and educational theater, interview instruments were modified and open-ended comments of the script were noted for future implementation of this project. The script was titled Not Otherwise Specified (see
Appendix C).
Experts' Comments on Interview Questionnaire
The lead project member emailed the interview questionnaire to two registered dietitians specializing in the field of eating disorders. Expert reviewers were asked to streamline the questionnaire and evaluate it for appropriateness.
Expert reviewer 1 recommended changes in the language to make it more consistent with treatment language. This expert commented that this would help interviewees understand the questions and feel comfortable with answering them. She also suggested not asking for too many specifics or details about their eating disorder behaviors because this can be triggering to the person. This reviewer added a general comment about the project stating, “Education about eating disorders should not contain any ideas for behaviors or numbers.” These suggestions were considered, and changes were made to the questionnaire.
Expert reviewer 2 provided general information regarding eating disorder behavior and stated that it was important for interviewees to comfortable and not judged.
31
She also made a similar comment as Expert 1's, stating that the questionnaire should not provide any ideas about engaging in behaviors. Suggestions were considered, and changes were made to the questionnaire.
Experts' Comments on Script
The lead project member emailed a video of the performance of the script and an evaluation form to two experts in eating disorders and two experts in the field of educational theater. All expert reviewers said that the content of the script was appropriate for adolescents with the addition of a guided post-viewing focus group discussion, and all experts agreed that the script could be used as a tool to engage adolescents with or without an eating disorder in conversation about the topic. The reviewers also were able to identify key themes and offered suggestions for improvement.
Expert Reviewer 1 reported that the script showed the “power of the eating disorder voice and how it takes over and limits one’s life.” This expert also felt that the script highlighted how social pressures play into eating disorders. She felt that the script was appropriate for older adolescents, but that middle-school age adolescents would need guidance for discussion.
Expert Reviewer 2 said that the “video illustrates the inner thought process of one suffering from an eating disorder by making seen and heard the voices that clutter the mind." This expert suggested that the content may need further clarification for those who are unfamiliar with eating disorders and that it is “too abstract” for an “introductory” audience. She suggested that follow-up discussions contain didactic education about eating disorders and how media and the subculture of pro-eating disorder online media
32
may contribute to disorders. In the space provided for open-ended comments, Expert 2 suggested that it may be validating for audience members to see that underlying issues such as trauma or family dynamics are acknowledged and that follow-up workshops could contain a format in which adolescents could create performances or expressive work of their own.
Expert Reviewer 3 identified key themes of isolation and loneliness within the script. She commented that the video may bring awareness to adolescents who may the recognize signs and symptoms of an eating disorder among their peers and additionally that it may support those who are suffering by showing them that they are not alone. This reviewer did not provide comments or suggestions for changes to the project.
Expert Reviewer 4 identified the key themes of control, loneliness, and isolation.
This reviewer stated that, “controlling their eating feels like they have control of their lives. That the disease feels like a friend—maybe the only one who cares about them and understands them. That even well-meaning real friends aren’t as important as the disease friend and how hard that can be on the friends." Expert 4 made similar comments as
Expert 3 about the ability of the script to raise awareness among adolescents who suspect a friend may have an eating disorder, and that for those with an eating disorder, it may show that they are not alone and that others may have similar thoughts and feelings.
Expert 4 stated that it was important that focus group discussions were set up in a way that adolescents felt comfortable engaging in conversation and that they did not have to out themselves. She suggested that conversations should provide viewers with resources to support their friends or that an adult should be available for students who wanted to speak privately. In the space provided for open-ended comments, Expert 4 stated that the
33
script was very “moving” and that she was curious about future plans for the project.
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CHAPTER V
DISCUSSION
The purpose of this project was to develop a script on the topic of eating disorders to increase eating disorder knowledge and awareness among adolescents with an ultimate aim at reducing the prevalence of eating disorders. This script is an educational tool that can be used as a school-based intervention program.
Findings and Modifications
The script Not Otherwise Specified was a collaborative effort by a team of nutrition and theater students and theater faculty from California State University,
Northridge. The project team leader emailed a video performance of the script to four expert reviewers. All reviewers gave positive feedback about the script. Suggestions were also given to improve the implementation of the project.
Several changes were made to the interview questionnaire based on feedback from experts. Additionally, the script was edited and modified throughout the rehearsal process based on discussions among the facilitators. However, experts did not comment specifically on the text of the script. All open-ended comments from experts have been taken into consideration and will be used to guide the implementation of post- performance focus group discussions.
Discussion of the Expert Evaluation
The formative evaluation improved the quality of the interview questionnaire. The original questions did not use treatment-oriented language and asked questions that may have been triggering to interviewees. To allow interviewees to feel more comfortable answering questions about their experience with an eating disorder, the questionnaire was
35
modified.
Findings suggested that the text of the script may be too difficult for young adolescents to understand. Therefore, future implementation of this project will be directed toward older adolescents in high school and beyond.
All experts stressed the importance of focus group discussions post-viewing of the performance. Based on these comments, focus groups discussions will not only include didactic education on eating disorders including basic information, pathogenesis and signs and symptoms, but will also include information about etiological factors such as family dynamics or trauma. One comment suggested that discussion of the subculture of pro-eating disorder online media not be included in focus-group discussion because it may give ideas to participants who may be currently struggling with weight control behaviors.
Other important findings include allowing participants to develop their own creative works. This finding is additionally supported by research. Haines, Neumark-
Sztainer, & Morris (2008) found that when students were given the opportunity to create a play based on their own experiences, it helped them take ownership and internalize the intervention message. Other research has found that engaging participants in the development of an intervention is more effective than using didactic education and that the messages are more likely to be relevant to the target population (Haines et al., 2006).
This finding demonstrates the value of developing lesson plans with theatrical activities in which students can express their own experiences related to eating disorders, dieting, body dissatisfaction, social pressure, or other contributing factors.
36
Additional findings suggest providing resources for eating disorder treatment and having an adult available to speak privately with anyone in need of support. This finding has been taken into consideration and will be implemented. The adults should be provided with eating disorder education and appropriate referral resources, such as mental health and nutrition professionals.
Limitations
The main limitation of this project was that the effectiveness of the script was not assessed by the target population. Future implementation of this project should address this by conducting pretest and posttest surveys that measure participants' knowledge and awareness as well as the usefulness of the project. Another limitation is that the script is designed for an English-speaking audience. As Expert 2 noted, some of the concepts are abstract and may be difficult to understand. Moreover, the script should not be used as an educational tool on its own and is meant to be complimented by focus group discussions.
Lastly, feedback on the script from experts was given based on a recorded performance.
Additional insight and feedback may have been overlooked because the script was not developed to be screened in video format. This medium is not as dynamic as a live performance, and nuances of the script and its impact may have been lost.
Implications
This script has the potential to serve as a tool for helping increase awareness and knowledge about eating disorders and to create dialogue about the subject among both student and educators. After viewing the script, students who may be struggling with eating disorders will feel a sense of connection and that they are not alone in their feelings. For students who have a friend who is struggling, this script may better
37
demonstrate what the friend is going through and allow for empathy and support. This educational tool can assist health educators in providing information about eating disorders in a more interactive manner, create open dialogue and provide a platform for support. Furthermore, it can serve as a guide for the development of scripts around other health topics.
The use of a formative evaluation by two eating disorder experts and two educational theater experts also provided important implications for those implementing this tool or other similar interventions. Getting feedback from experts ensured that focus- group discussions, and perhaps subsequent creative workshops, provide a guided discussion with predetermined curricula (see Appendix D). Therefore, ongoing evaluation during the development of curricula should be conducted with both experts and the intended target population to ensure that the information provided is appropriate and useful.
Conclusion
The purpose of this graduate project was to develop an original script, Not
Otherwise Specified, to increase awareness and knowledge about eating disorders among adolescents. Research has indicated that intervention during early adolescence and continued through young adulthood could be beneficial in the prevention of disordered eating habits or eating disorder onset (Neumark-Sztainer et al., 2011; Heatherton et al.,
1997; Kotler et al., 2001). A formative evaluation determined that post-performance focus group discussions should be conducted to present basic eating disorder information, pathophysiology, and etiology, including family dynamics and trauma. Lesson plans should be developed to create a more interactive workshop after discussions so students
38
can create their own theatrical works. Moreover, resources for treatment as well as a trained professional will be made available for those requesting additional support. This script was developed as a tool to help increase eating disorder awareness and knowledge, such that it may reduce the incidence of eating disorder onset among adolescents in the future.
39
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APPENDIX A
INTERVIEW QUESTIONNAIRE
In order to develop this project, we were fortunate enough to speak with eight individuals who have struggled with a diagnosis of an eating disorder. We utilized the following questionnaire to guide our conversations.
Questionnaire:
1. Current age; age of start of ED?
2. What ED were you first diagnosed with? Did your diagnosis ever change?
3. What do you feel originally triggered to your ED?
4. What need did the ED fulfill?
5. What messages did you receive about weight/ body image growing up?
6. What were some of the first signs/ symptoms of the ED?
7. What are your personal/specific triggers?
8. Is/ was compulsive exercise a behavior that you exhibited?
9. Do/did you ever use laxatives?
10. How many hours of the day do/did you spend thinking about food?
11. If you weren’t thinking about food/ weight what do you imagine you would be feeling?
12. Who knows about your ED?
13. What type of support did your family/friends provide? Or did they?
14. If a friend suspected your ED, how would you like them to approach you to provide help?
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15. If you were an acquaintance of someone with an ED how would you approach them to provide help?
16. What do you think are the most misunderstood things about ED?
17. What is scary about recovery?
18. What type of treatment did you seek? or receive?
19. Are you currently still receiving treatment?
20. If you can think back to before you decided to seek treatment, what kinds of things might have been helpful to push in that direction
49 APPENDIX B
Script Development Activities
Write Around
Scene 1: Fast Food Restaurant
PH: What are you going to get?
DK: I am so hungry. I can eat anything! Maybe a McDouble?
PH: Right?! That sounds good. I never know what to get here. What do you want?
DT: Ummm. I don’t know. Nothing sounds good. Is there anywhere else we can go?
PH: There isn’t any other place to eat around here and I’m starveballs! I think I’m just going to get a cheeseburger and fries.
DK: Ohh. That sounds good! (Looks to DT) What about a salad?
DT: (Looking dazed and confused) Uhhh. Yeah, but the salads have so much stuff on them. You guys order. I’ll figure is out or get something later. I’m not that hungry. Really.
PH: GURRLL!!
DK: How are you not hungry?! We haven’t eaten since 1pm and it’s 7!
DT: (Shrugs shoulders)
PH: Well, I’m going to order. I’ll order you a salad. What salad do you want?
DT: Order whatever you want. The salad is fine.
PH: Which one?
DT: I don’t care. I just want to get out of here.
DK: We will leave after we eat. We definitely need to eat something. Stop being so complicated!
DT: Sorry. I’m not trying to be complicated. I told you guys to order and not to worry about me. I told you I’m not hungry.
PH: Fine. I’m getting you a salad.
DT: Fine
Scene 2: Bathroom
M: (Knocks on bathroom door)
S: I’m busy!
M: I just wanted to talk to you for a second
S: Well I’m putting my makeup on right now
M: Maybe you can teach me how to put my makeup on? You promised you would.
S: Now isn’t a good time. Go away and just let me do my makeup.
M: We haven’t hung out in a while. Can I at least watch?
S: NO! You’re driving me crazy. Just let me be alone. Please!
M: Why are you being like this? I need my older sister and you’re hiding behind a door.
S: You don’t need me this second. (Turns on music loudly)
M: (Yelling over music) I DO! Can you just open the door for a sec. I need to grab something from the medicine cabinet.
S: (Opens door quickly and chucks a medicine bottle out the door. Then quickly shuts door again). THERE!
M: (Reads label confused) What is this? You don’t even know what I needed. I’m getting mom and dad!
S: No don’t do that. (Opens door) Fine. Get what you want and then let me be.
M: (Walks cautiously around. Slowing browsing the medicine cabinet, finally deciding on a band-aid) Got it! Thanks. You know since I’m already in here might as well chat. How’s school?
S: Oh My GOD. Get out!!
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Accordion Poems
Perfection Equals Distortion
Perfection equals distortion
Yet distortion equals acceptation
I can’t look at myself
My face bloated and red
My eyes fill with tears
Finally I am able to cry and grieve. Sorrow is mine
But don’t cry for too long
Or do. You could afford to lose the water weight
Yes. I feel free.
But just for a moment. What will happen tomorrow?
Will I disappear? Fade away? Be forgotten?
Not that it matters to anyone.
There is No Thought
There is no thought. Just survival mode.
Just survive somehow.
Get through the day so you can go to sleep and not have to think anymore
Thoughts of failure, of despair, of loss
I am not in control. I am not the boss
Get a hold of yourself!
Control has slipped away
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I am drowning. Just let me float down.
No. I am drowning. Please save me.
All the watery depths. Dark hidden caves below
Nothing can save me from this
No one can help me through this
Why can anyone help me?
Why can’t I help myself?
More Addictive Than Any Drug
A craving. A buzz beyond words.
Too many carbs, too much sugar. Not enough weight loss
Run faster, just higher, eat less
Strength is power. Power is strength
Keep going. Don’t give in
Once relentless and care free, generous and loved
People come and go. My ED remains loyal
No matter who loves me, my ED loves me more
I’m More Powerful Than You. I Don’t Have to Rely on Food.
I am strong like an ultimate fighting champion
I am stronger than you
I prevail. I conquer. I am undaunted
But yet I’m still haunted
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Haunted by my ghost. By the skeleton of a women who once stood before me
Who am I anymore?
What do I care about anymore?
I don’t care about myself
I care about them. The voices, the thoughts, the stares
But they are monsters
I am a monster.
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APPENDIX C
SCRIPT: NOT OTHERWISE SPECIFIED
(Shay stands in the center)
SHAY
Alone.
CHORUS
A number. A statistic. A percentage.
SHAY
I want to be happy with how I look.
CHORUS
You? Nothing's wrong with you.
SHAY
I want to be liked.
CHORUS
You? You've always been so athletic.
SHAY
I want to know who I am.
CHORUS
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You're a winner.
SHAY
I want to fit in.
CHORUS
You don't really meet the criteria. You're not really at the threshold. It's just, it's just... society's expectations.
SHAY
Hold on. Hold on. I want to know why I have these thoughts.
CHORUS
Don't think.
SHAY
Don't think? Hold on.
CHORUS
DO! Work out -- run fast, jump high, eat, don't eat. Control. Eat don't eat. Power. Eat don't eat.
SHAY
I can't handle this.
CHORUS
Run fast. Jump high. Eat don't eat.
SHAY
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Leave me alone.
CHORUS
Run fast, jump high, eat don't eat.
ANNA
I can help you do this.
CHORUS
Jump fast. Run less. Eat don't eat.
(Shay stops. Out of breath) (Shay stops. Out of breath)
Don't stop.
SHAY
Never stop.
CHORUS
Keep going.
SHAY
Never quit.
CHORUS
BREATHE! Jump fast. Just breathe. BREATHE! Run less. That's not it. Eat... eat...
SHAY
Okay.
(Everything stops. Temptation - food)
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CHORUS
A silent cry for help.
A dark invisible hole.
Fill the hole. Just fill the hole.
ANNA
Did you eat? Did you eat something today?
CHORUS
Unwanted.
Is anyone going to ask her if she's okay?
If someone cared, you would see something is wrong.
She needs a connection. If she had something...
...anything...
...anyone...
SHAY
I have a friend. Her name is Anna. She's my friend. She's my manifestation. My monster.
ANNA
No. Your friend. Your best friend.
CHORUS
When you're this low, it's the only thing you have.
SHAY
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Not the only thing. I just got a job.
ANNA
You shouldn't have done that.
SHAY
I just got hired for the Halloween Hall of Horrors.
ANNA
That's cute.
SHAYLA
Part of the job requires me to attend Fright School. To learn how to be a monster.
CHORUS (DIVIDE LINES)
I love that show // chain saws; knives; ghosts; severed arms, body parts; My friend got so freaked out by it, she puked
(Uncomfortable awkward pause)
SHAY
I'm learning how to be a monster.
ANNA
What's so funny?
SHAY
I already feel like a monster.
ANNA
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Ooooo scary.
SHAY
Her name is Anna. Not really a monster name. I named her. I gave her that name, I don't know why. I've heard people do that. Anna is my best friend.
CHORUS
I've heard people do that.
SHAY
My only friend.
CHORUS
People with eating disorders do that.
(McDonalds order)
ANNA
I'm more powerful than you. I don't have to rely on food
BELLE
What are you gonna eat?
ELSA
I'm so hungry, I can eat anything. Maybe a McDouble.
BELLE
A McDouble sounds good. I never know what to eat here. What do you get, Shay?
SHAY
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Ummm. I don't know. Nothing sounds good.
ELSA
I'm starveballs. Let's go. We need to commit.
ELSA
I'm gonna get a cheeseburger and fries.
BELLE
That sounds good.
SHAY
You guys order. I'll figure it out or get something later. I'm not that hungry.
BELLE
Girrrrlll!?! Are you ever hungry?
ELSA
How are you not hungry? We haven't eaten since early this morning.
BELLE
Just pick something.
SHAY
I want to get out of here.
BELLE
We will leave after we eat.
ELSA
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Stop being complicated.
SHAY
Sorry. I'm not trying to be complicated. Don't worry about me. I'm... not hungry. Really.
ELSA
Get her a salad.
BELLE
I'm ordering you a salad.
(Shay and Anna break away) (Shay and Anna break away)
ANNA
You are strong like an Ultimate Fighting Champion.
SHAY
I am stronger than them.
ANNA
You prevail, you conquer, you are undaunted.
SHAY
But I am still haunted. Haunted by the ghost, by the skeleton of a woman who stands before me. Who am I anymore? What do I care about anymore. Invisible.
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APPENDIX D
Focus Group Discussion Education Guide
• What is an eating disorder?
• Types of eating disorders
o Causes and consequences of eating disorders
o Signs and symptoms of eating disorders
• Treatment for an eating disorder
• Available resources
What is an eating disorder?
• Eating disorders are mental illnesses that can be characterized by a disturbance of
eating habits or weight control behaviors that result in significant functional
impairment, emotional distress, and medical problems (Rohde, Stice, & Marti,
2015).
• Eating disorders can affect people of every age, sex, gender, race, ethnicity, and
socioeconomic group. National surveys estimate that 20 million women and 10
million men in America will have an eating disorder at some point in their lives
(NEDA, 2018).
• The pathogenesis of eating disorders is multifactorial with psychological, social,
and biological elements. Factors that contribute to eating disorders include both
risk factors such as body dissatisfaction, internalization of thin-idealization,
dieting, and lack of familial support (NEDA, 2016) and other correlating factors
such as genetics, social pressures, family dynamics or history of trauma.
Types of eating disorders
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• The most common forms of eating disorders include anorexia nervosa, bulimia
nervosa, and binge eating disorder. They affect both females and males.
• Anorexia nervosa is an eating disorder characterized by weight loss (or lack of
appropriate weight gain in growing children); difficulties maintaining an
appropriate body weight for height, age, and stature; and, in many individuals,
distorted body image. People with anorexia generally restrict the number of
calories and the types of food they eat. Some people with the disorder also
exercise compulsively, purge (via vomiting or laxatives), and/or binge eat
(NEDA, 2018).
o Signs and symptoms of anorexia nervosa (limited list)
§ Dramatic weight loss
§ Preoccupation with weight, calories, and dieting
§ Restriction of whole food groups
§ Concern about eating in public
§ Constipation, cold intolerance, abdominal pain
§ Loss of menstrual period
§ Dizziness
§ Inflexible thinking (NEDA, 2018)
• Bulimia nervosa is a serious, potentially life-threatening eating disorder
characterized by a cycle of bingeing eating and compensatory behaviors such as
self-induced vomiting designed to undo or compensate for the effects of binge
eating. Recurrent binge-and-purge cycles of bulimia can affect the entire digestive
system and can lead to electrolyte and chemical imbalances in the body that affect
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the heart and other major organ functions (NEDA, 2018).
o Signs and symptoms of bulimia nervosa (limited list)
§ Evidence of binge eating, including disappearance of large
amounts of food in short periods of time or empty wrappers and
containers, indicating consumption of large amounts of food
§ Evidence of purging behaviors, including frequent trips to the
bathroom after meals
§ Skipping meals or having small portions
§ Stealing or hording food in strange places
§ Unusual swelling of the cheeks or jaw area
§ Calluses on the back of the hands and knuckles from self-induced
vomiting
§ Concern with weight and body shape and frequent dieting
§ Body weight is typically within the normal weight range or may be
overweight.
§ Discolored teeth
§ Mood swings (NEDA, 2018)
• Binge eating disorder (BED) is characterized by recurrent episodes of eating large
quantities of food (often very quickly and to the point of discomfort); a feeling of
a loss of control during the binge; experiencing shame, distress or guilt
afterwards; and not regularly using unhealthy compensatory measures (e.g.,
purging) to counter the binge eating. It is the most common eating disorder in the
United States (NEDA, 2018)
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o Signs and symptoms of BED (limited list)
§ Evidence of binge eating, including disappearance of large
amounts of food in short periods of time
§ Creates lifestyle schedules or rituals to make time for binge
sessions
§ Disruption in normal eating behaviors, including eating throughout
the day with no planned mealtimes; skipping meals or taking small
portions of food at regular meals; and engaging in sporadic fasting
or repetitive dieting
§ Fluctuations in weight
§ Low self-esteem
§ Noticeable fluctuations in weight, both up and down
§ Stomach cramps, other non-specific gastrointestinal complaints
(constipation, acid reflux, etc.)
§ Difficulties concentrating (NEDA, 2018)
Treatment for eating disorders
§ Interventions for eating disorders include psychological counseling or
psychotherapy in conjunction with nutritional and medical monitoring (NEDA,
2018). Psychological counseling focuses on underlying conditions that have
contributed to the onset of the eating disorder and current eating disorder risk
factors or behaviors. Additionally, analysis of the family context is relevant,
especially for adolescents, and incorporating family therapy approaches has been
beneficial (Costa & Melnik, 2016).
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