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. viii 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 1 (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% 2 reduction in eating disorder behaviors in a three-year follow up relative to a control condition. Although