Tell me about your mother: straightening out the role of family in the etiology, maintenance, and treatment of eating disorders

by Joye C. Anestis

As most of our parents have pointed out to us (most likely when we were angst-y teenagers), being a parent can be pretty rough - sleepless nights, mountains of worry, little in the way of gratitude, and often the majority of the blame if something goes awry in a child's life.  It's a wonder we continue to have kids!  Historically, the world of clinical psychology has done little to ease parents' burdens.  In fact, many researchers and therapists have increased that burden by promoting the idea that mental illness in the child is the direct result of misbehavior by a parent (usually the mother).  Some psychologists continue to espouse this idea even in the face of ample evidence to the contrary.  This is especially the case for eating disorders, where theories of "anorexogenic" parenting flourish in some circles.   "Anorexogenic" family patterns are similar to now discredited theories of "schizophrenogenic" and "autistogenic" mothers - the basic idea is that particular styles of interaction among family members play a specific role in the etiology and maintenance of mentally ill behavior.  In short, eating disorders are the direct result of some parental mistake.  Thankfully, the Academy for Eating Disorders (AED) has published a position paper elucidating the role of family in eating disorders.

Before I get into the meat of this position paper, I want to make two comments.  First of all, mental illnesses are complex constructs - anyone who has ever had one or ever attempted to treat one can attest to that.  Identifying one single cause (such as parenting style) is difficult, if not impossible.  Most of the well-validated theories of causation in clinical psychology acknowledge a multitude of factors which interact to produce disordered behavior in an individual, factors such as genetic variables, individual personality traits, specific environmental experiences, and individual beliefs about those experiences.  Simply blaming the parents seems to me to do a disservice to the complex and unique people and constructs that clinical psychologists face.  While the simplest theories are often considered the best (Occam's razor), there are situations in which danger arises from being overly simplistic in determining causation - the danger in this instance, alienating and condemning parents who might be valuable resources in treatment. Keep in mind that I am speaking of being overly simplistic in determining cause...it has been well-established that the simpler treatments are often the best.  The second thing I want to point out is that the family-based theories implicated in the AED position paper differ greatly from other family variables that we have discussed in terms of other mental illnesses.  For example, expressed emotion has been identified as a factor that exacerbates schizophrenia and bipolar disorder.  This is a  hostile and critical family interaction style that influences patient outcome...it is not believed to cause these disorders, which have clear biological bases.  By being critical of the role of family in the development of eating disorder, neither I nor the authors of this position paper are arguing that family interaction styles have no effect on behavior.  What we do argue is that family factors are not enough, other factors play a larger role, and that it is more prescient to focus our energy on using family members as allies to help young people recover from eating disorder than to assign blame on the parents.

So I step off the soapbox and return to the empirical data...what does the data tell us about the influence of families in the etiology, maintenance, and treatment of eating disorders in young people?  The AED position paper, written by Le Grange, Lock, Loeb, & Nicholls, does an excellent job of succinctly summarizing this issue (look for it on the AED website, as well as in the International Journal of Eating Disorders).

Family Factors in the Etiology of Eating Disorders

Research on family risk factors is sparse, but no data to date support the assertion that families are causal in the development of eating disorders (mothers everywhere breathe a sigh of relief).  Both the retrospective/cross-sectional studies and prospective/longitudinal studies that have been conducted possess severe limitations.

• Cross-sectional research: A variety of risk factors have been implicated in the development of eating disorders including: inappropriate parental pressures; early-life "overprotective/high-concern" parenting behaviors; parental indifference, family discord, lack of parental care, and greater adversity; significant change in the family structure in the year before eating disorder onset; high parental expectations, low parental contact, and more family criticism about shape and weight; and more parental problems such a separation, arguments, criticism, high expectations, over-involvement, under-involvement, low affection, and critical comments about shape, weight, or eating.  Le Grange et al. note that, due to the methodological limitations inherent in cross-sectional studies (i.e., causation cannot be proven with this type of study), the findings most likely indicate that these parental/family factors are risk factors of psychopathology in general and are not specific to eating disorders.  Furthermore, it is most likely that these risk factors interact with more specific biological vulnerabilities that ultimately give rise to particular phenotypes of disordering eating (Klump et al., 2009).
• Longitudinal research: The prospective studies on this topic are inconclusive.  Three have found family variables to be important and three have not.  Again, the authors note that these studies lack the methodological rigor necessary to fully answer the questions at hand (problems include lack of psychiatric controls to determine specificity of the associations found, lack of adequate statistical power, and use of assessments with questionable reliability and validity).   Prospective, longitudinal studies are the only way this causal question can be answered, but so far no answers have arisen.
• The Role of Genetics: The role of genetics in the development of eating disorders, on the other hand, has been more clearly elucidated, and evidence continues to mount that heritable influence underlie both anorexia and bulimia.  I find it interesting that genetic factors do highlight a family influence for eating disorder development, but it is a very different type of influence than the one promoted by theories of "anorexogenic" parenting.  Importantly, no single gene or genomic region has been reliably implicated; however, again it is highly likely that a multitude of risk factors, genetic, environmental, psychological, cultural, etc., interact to influence susceptibility to eating disorders.

The Role of Parents in the Resolution of Eating Disorders

Involving family members in the treatment of eating disorders has been covered on PBB before (family-based treatment for anorexia and incorporating family in treatment for children & adolescents), so I won't repeat what we've already said.  I will just note that family involvement in treatment of eating disorders in young people (especially anorexia) appears to be useful in reducing both psychological and medical morbidity.  Furthermore, family inclusion in treatment is acceptable to both parents and patients, resulting in lower attrition rates.  The literature here is stronger for anorexia than for bulimia (but other treatment options exist for bulimic patients). The position paper does not go into great detail describing the evidence for these treatments, as most of their energy was spent discrediting theories which blame parents for creating eating disorders in their children.  For more information on this topic, see previous PBB articles on these treatments, browse our bookstore for resources, and download some essential IJED articles for free.

It is the conclusion of the AED position paper that families should be included in the treatment of most young people with eating disorders.  Their take-home point is that utilizing family members as an asset in the treatment process should take precedence over assigning blame for the disorder.  Parents feel enough guilt on their own without psychologists telling them that their child's problems are all their fault.

Joye Anestis is a doctoral candidate in clinical psychology at Florida State University.