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Introduction
Eating disorders (ED) are illnesses with a multifactorial origin, in which several individual, family and social factors create a predisposition to trigger or prolong them (Garfinkel & Garner, 1982). The first findings on voluntary food abstinence date from the 14th century (Toro, 1999), when Morton was the first to indicate the importance of the family environment in 1760 (Silverman, 1985). However, Gull in 1874 and Lasègue in 1873 (cited in Toro, 1999) emphasized the importance of excluding the family as a form of treatment for anorexia nervosa (AN). Subsequently, Bruch (1982), Selvini-Palazzoli (1974) and Minuchin, Rosman and Baker (1978) focused on describing the characteristics of families with a member with an ED, since they considered that these characteristics could be modified and thereby contribute to patients’ recovery. These authors observed that these were rigid family systems, which exercised excessive control over their daughters, and therefore failed to support the process of individuation and separation during adolescence. They are also characterized by high expectations, undefined family roles and poor conflict resolution skills.
More recent empirical evidence also highlights parents’ influence on the development of an ED in their children (Brown & Geller, 2006; González-Macías, Romero, Rascón & Caballero, 2013; Guelar & Crispo, 2001; Loth, Neumark-Sztainer & Croll, 2009; Mateos-Agut et al., 2014; Quiles, Quiles, Pamies, Botella & Treasure, 2013). Studies that have explored the characteristics of families with a member with an ED show that parents have limited skills for addressing problems or conflicts, implement rigid, unpredictable norms and tend to be demanding, unaffectionate and establish ambivalent bonds (Mateos-Agut et al., 2014; Ward, Ramsaid & Treasure, 2000). These are also families that exert parental control that prevents decision-making, individualization and autonomy in their children.
Adolescents with eating disorder symptoms perceive their parents as controlling rather than as supportive figures who encourage family union (Berge, Loth, Hanson, Croll & Neumark-Sztainer, 2011; Brown & Geller, 2006; Dring, 2015; Lampis, Agus & Cacciarru, 2013; Loth et al., 2009), particularly in response to traumatic events such as a serious illness, the death of a family member or sexual abuse (Tagay, Schlottbohm, Reyes-Rodríguez, Repic & Snef, 2014). Dúo, López, Pastor and Sepúlveda (2014) state that promoting dependence in their daughters, parental conflict (in which the daughter is trapped by divided loyalties), conflict avoidance and parents’ lack of involvement in raising their children are related to the development and maintenance of ED.
Various studies report that parents’ conversations regarding body weight or diets (Neumark-Sztainer et al., 2010), and teasing or negative comments in the family unit, particularly those referring to eating patterns and body shape, are linked to the development of EDs (Krug et al., 2013; Loth et al 2009; Meno, Hannum, Espelage & Douglas, 2008; Neumark-Sztainer et al., 2010; Quiles et al., 2013; Smart & Tsong, 2014). Moreover, De la Corte (2016) recently reported the influence of parents’ perception of adolescence and educational styles on the development of EDs, noting that the prevention of eating disorders requires teaching parents good parenting practices, which encourage the autonomy of their teenage offspring.
In this context, this study seeks to provide information that will shed light on the family factors related to the development of an ED, such as support, expressing affection and emotions, problem solving, difficulties in detecting the state of risk and negative attitudes towards their daughter’s diet, weight and body shape. These could be useful for developing prevention strategies designed for parents. Accordingly, the purpose of this research is to identify and understand the family aspects associated with the development of ED, based on the perception of parents of a daughter with an ED, and women suffering from the latter.
Method
Participants
Two groups of participants were formed: 1. Four women diagnosed with an ED, all from and living in Mexico City, two with bulimia nervosa (BN), one in full remission and another in partial remission. The other participants had an eating disorder not otherwise specified (EDNOS), one of whom was in full remission while the other undergoing treatment (see Table 1); and 2. Five parents (four women and one man) of a daughter with an ED, two of whom were a married couple (see Table 2). The diagnosis of the participants with an ED was established on the basis of the DSM-IV-TR criteria (American Psychiatric Association, 2002). Table 3 shows the family characteristics of the participants.
Table 1 Characteristics of participants with an eating disorder.
| ID | Age | Diagnosis | Age of onset of ED and treatment | Civil status | Level of education | Occupation | Family and childhood characteristics | Moment when parents became aware of ED |
|---|---|---|---|---|---|---|---|---|
| 1 (A) | 24 | BN Recovered | 15 (four years later) | Single | Bachelor’s degree | Student and financial advisor | Only child. The father did not live with her because he had another family. “A” was overweight as a child | She told her mother. |
| 2 (D) | 22 | AN Partial remission | 15 (two years later) | Single | Bachelor’s degree | Student | First of two daughters. Her father was away from home for years, and her mother suffered from depression. “D” was overweight as a child | When her weight started to drop drastically (10 kg in two weeks). |
| 3 (X) | 18 | EDNOS-Restrictive Recovered | 16 (six months later) | Single | High school | Student | First of two daughters. Diabetic father. “X” was underweight as a child. | When they observed her downcast mood, lack of appetite and weight loss. |
| 4 (C) | 39 | EDNOS-Restrictive In treatment (for four years) | 18 (17 years later) | Single | Bachelor’s degree | Assistant for academic programs | Second of three children. Her parents separated when she was four years old. | She realized based on the information provided by a specialist on the radio. |
Notes. AN = Anorexia nervosa; BN = Bulimia nervosa; EDNOS = Eating disorder not otherwise specified; ID= identification code.
Table 2 Characteristics of parents of women with an eating disorder.
| ID | Age | Civil status | Level of education | Place of birth | Place of residence | Occupation |
|---|---|---|---|---|---|---|
| 1 (Mother of A) | 47 | Single | Bachelor’s degree | Mexico State | Mexico City | Administrative manager |
| 2 (Mother of D) | 52 | Consensual union | Technical studies | Mexico City | Mexico City | Housewife |
| 3 (Mother of X) | 40 | Married | High school | Mexico City | Mexico City | Housewife |
| 4 (Mother) | 56 | Married | High school | Mexico City | Morelos | Housewife |
| 5 (Father) | 54 | Married | Bachelor’s degree | Mexico State | Morelos | Unemployed |
Instruments
This was a qualitative study, which used a semistructured interview to gather information. The interview guide included questions on family support, expressing emotions, family cohesion, problem solving, teasing and negative comments on diet, shape and body weight, as well as stressful life situations and transition in the family’s life cycle. The questions were retrospective, in other words, respondents were asked about three moments in time: before the onset of the ED, the moment when the ED emerged and after recovery. However, this study only reports on the first two moments.
Procedure
The population of interest was contacted through ED treatment specialists. Respondents signed an informed consent form, which authorized their anonymous and confidential participation, and the audio recording of the interview. The latter lasted between 90 and 120 min for each respondent, and were transcribed verbatim; content analysis was also undertaken to identify the family aspects associated with the background and onset of the EDs (Denzin & Lincoln, 2005; Kvale, 2007; Vasilachis, 2006).
Results
Two categories of analysis emerged: 1) difficulties with parenting practices, and 2) negative attitudes of parents towards their daughters’ diet, weight and body shape, as shown in Figure 1. Below are descriptions of each of the categories, and testimonials by the participants to illustrate them. Each testimonial is identified using the interviewee’s first initial and age, as they appear in Tables 1 and 2.
Difficulties in parenting practices
Family factors were linked to inadequate parenting practices and the development of an ED. Respondents expressed the difficulties their parents experienced in raising them properly during their childhood and adolescence, which were related to the ED both prior to and after its onset.
Difficulty providing support in crisis situations
All the respondents declared that, both prior to and after the onset of the ED, their parents found it difficult to support their daughters in situations they identified as involving “crisis” or change, such as the breakup of a couple relationship, the start of adolescence, the father’s problems with alcoholism, conflicts between the parents, moving house and changing school. The respondents hoped for support from their parents in the form of being listened to, understood and accompanied in situations they regarded as “crises.” The parents who participated identified and admitted their lack of understanding and support of their daughters in these situations, which may have contributed to the development of the ED.
“I moved house, I changed school, I was changed into the second year of elementary school... I felt abandoned by my Mom, I felt sad... very sad” (A, 24 years old).
“At that time X began to date a boy... her Dad did not approve. I believe that her Dad’s failure to understand affected her. Then X developed an eating problem” (Mother of X, 40 years old).
Difficulty expressing affection
Both the respondents with an ED and the parents agreed that, before the disorder developed, they found it hard to express approval and affection towards their daughter, or show them affection (e.g. through hugs and/or caresses).
“I found it hard, and still do, to express this... to tell her how I feel. As a man, it is not easy. We were not taught to talk about what we were feeling, and our children do the same” (Father of patient with ED, 54 years old).
“I found it difficult to express my affection and hug her. Moms are expected to be close to and embrace their daughters... daughters approach their mothers to snuggle in their arms, and say ‘I miss you, I love you!’ We did not do any of this... instead it was ‘Hi, how are you?’” (Mother of A, 47 years old).
Difficulty establishing a relationship of trust with the daughter
All the respondents with an ED perceived attitudes of authoritarianism, demandingness and overprotection in their parents, which prevented them from feeling secure or confident enough to make decisions, expressing their expectations, moving away from the family unit and creating their own identity. Instead, they tried to meet their parents’ expectations.
“I came to believe that my Mom had expectations of me, expectations that ranged from school to my personal life. Today, at the age of 39, I have never asked myself what my own expectations are. I have always complied with other people’s expectations, particularly my Mom’s” (C, 39 years old).
“Our relationship deteriorated. She did not reply when I asked her questions... she did not say anything at all. She would always say, ‘I do not trust you.” (Mother of A, 47 years old).
Difficulty expressing and listening to emotions
Both groups identified the difficulty within their family unit of expressing and listening to emotions, principally anger, fear, sadness, inadequacy and guilt, which were directly linked to the onset of the ED.
“I had all these ideas that ‘I am not comfortable with my body!’, and there was no way that I could discuss these topics with my Mom!” (C, 39 years old).
“I think this might be the first factor that triggered the disorder, and one of the main causes was the failure to express emotions. Our family relationships were very superficial, very routine... and we did not listen to each other’s sadness, happiness or problems... I think that was what happened” (D, 22 years old).
Difficulty solving and addressing problems
Both groups perceived the difficulty of solving conflicts or problems within the family, which they associated with the development of the ED. The parents identified the fact that, prior to the onset of the ED, they were unable to speak about the difficulties or conflicts that arose within the family, and could therefore not solve the disagreements or problems that emerged, and on the contrary avoided, ignored or denied them. On the other hand, respondents suffering from an ED said that the inability to discuss problems as a family and find solutions for them, was an aspect related to the development of the disorder. The factors that triggered family conflicts were arguments and violence between the parents, the difficulty of agreeing on the daughter’s upbringing, and the father’s alcoholism. Therefore, difficulty solving conflicts triggered the disorder, whereas improving this situation prompted patients’ recovery.
“I think that’s what made D explode: not solving or addressing problems. I preferred to avoid dealing situations and looking for solutions or alternatives to overcome them, and I avoided fights and problems” (Mother of D, 52 years old).
“I told my Mom about it. I did not know why I had decided to vomit, and I told her... I think that at that moment she did not know what to do. I do still not know whether it worried her, or if she thought that I was exaggerating... or that it was not true. But it did not seem to matter to her at the time” (D, 22 years old).
Difficulty identifying the onset of the disorder
Parents declared that they had failed to identify the onset of the ED in their daughters, while the majority of participants with a disorder remembered that they told their parents about it.
“I did not realize that something was happening... perhaps the disorder had already been present for longer... and I had not realized.” (Mother of X, 40 years old).
“I had a low moral, which made me lose much of my appetite, and my parents noticed that I looked worn out. I think I looked thinner than usual... my Dad insisted that nothing was wrong” (X, 18 years old).
Parents’ negative attitudes towards diet, weight and body shape
Using the input of parents and respondents with an ED, a second category was established concerning all the negative attitudes towards their daughters’ diet, body weight and shape. To this end, several subcategories were identified, which are described below and illustrated with a number of vignettes.
Dissatisfaction with the daughter’s body weight or shape
Both groups of participants said that there was dissatisfaction with the daughter’s body weight or shape. The parents expressed disagreement, irritation or intolerance towards their daughters’ body weight and/or shape. Conversely, participants suffering from an ED said that they felt that their parents, particularly their mothers, were not satisfied with the shape of their bodies or their weight.
“One day we went out to buy clothes, and that seemed to spark off something for her. I was getting desperate because nothing she chose fitted her, so... somehow she interpreted that as my rejection of her. I believe that the disorder began when I said ‘Let’s go, just take anything, nothing looks good on you!’” (Mother of A, 24 years old).
“We treated her as the ‘fat one’, and at home everyone called her ‘fatty’” (Mother of patient with an ED, 56 years old).
Comparison based on body weight or shape
The parents declared that they made comparisons regarding their daughter’s body weight and shape, but did not think that this had a negative impact. Respondents with an ED regarded these comparisons as a form of rejection, which made them believe that they were not physically what their parents expected them to be.
“I would call my elder daughter ’skinny’... because she was skinny. I did not use the same adjective for G, but I did not call her fat either... yet she thought that I did, because we did not call her ‘skinny’” (Parent of patient with an ED, 54 years old).
“My Mom told my ballet teacher that ballet was for skinny girls, and once said to her ‘Have you seen what D looks like?... she will not be able to dance... I think that ballet is for very slim people.’ I remember this vividly, and from then on I was unable to dance... I never learned how to dance ballet” (D, 22 years old).
Food restrictions
Both parents and respondents with an ED perceived that, during childhood, the diet was restricted in terms of quantity or type of food, to prevent the daughter from eating too much, or what she wanted to, whether inside or outside the home.
“When I thought that she looked fat, I said ‘Alright... that’s fine’. But I was demanding with food. When she went to her Grandma’s house that was different: her Grandma gave us huge portions... as much as we wanted. I would say to her, ‘Be careful! Be careful!’ Even my nieces and nephews said to me, ‘Leave us alone!’ Then, when we went to the cinema, I would take them candies, though everything was always limited. But when A was alone at home, she could eat whatever she wanted, and throw away whatever she wanted” (Mother of A, 47 years old).
Concern with body weight
In both groups of respondents, it emerged that parents’ concern with their daughter’s increase in body weight was a factor associated with the onset of an ED, which the participants with an ED regarded as a form of rejection or non-acceptance.
“I am not as concerned with her weight any more, but I used to be” (Father of patient with an ED, 54 years old).
“When I was ten, I started to see a nutritionist, because my mother was worried and I now realize she was worried her daughter might be sick. But I saw it as ‘No, she does not accept me, she does not love me!’” (A, 24 years old).
Expression of affection based on body Weight or shape
Parents expressed affection, in the form of words of approval or fondness, towards their daughters who had a “slim” body, but not towards those who did not.
“In my family, my grandmother and uncles and aunts would judge and favor physical appearance, and say what was ideal...and whoever met these standards was accepted. When a new grandchild or anyone was born, they would say: ‘Look... this one is fair skinned!’ Whereas they would always say of one aunt: ‘She is so fat... she is always eating, despite knowing how fat she is!’” (C, 39 years old).
“I think that one of these comments might have affected her. My other daughter is very slim, whereas G is a little chubbier... and she started to feel different. The other one was very slim, and everyone would say: ‘She is so pretty!’ …and so on and so forth…and G felt fat” (Mother of patient with an ED, 56 years old).
Discussion
The purpose of this research was to identify and understand the family aspects associated with the development of ED, based on the perception of parents of a daughter with an ED, and women suffering from the latter. The main finding was the identification of the difficulty parents of a woman with an ED experience in engaging in adequate parenting practices with their daughters, during childhood and adolescence, which was related to the development of EDs. However, parenting practices are essential for raising children, through support and control (Andrade & Betancourt, 2008). Specifically, this study that parents found it difficult to provide support for their daughters during situations of change or crisis, such as the beginning of adolescence. This is a stage with numerous changes that involve constructing identity and autonomy. A family environment that encourages self-esteem, decision-making capacity and separation will make it easier for teenagers to achieve the objectives of this period (De la Corte, 2016). This coincides with the fact that in this study, the disorder began during adolescence in all the respondents with EDs.
Moreover, the results suggest that parents found it difficult to support their daughters, by listening, understanding and accompanying them in situations they regarded as a “crisis”, and to express affection towards their daughters. On this subject, several authors have highlighted the importance of parents manifesting their support, by showing love and affection to their children (Brown & Geller, 2006; Loth et al., 2009). This enables them to accept themselves, feel affection towards themselves and develop their self-esteem and identity (Andrade & Betancourt, 2008).
During this stage, the ED could have become a means of finding their “identity.” Authoritarian control by parents has been reported since the Middle Ages, when an ED was referred to as an illness characterized by weight loss due to a “hunger diet” self-imposed as a religious practice, and as a sign of penitence and remorse for sins committed by the faster (Lopez, Nuño & Arias, 2006; Toro, 1999). Dring (2015) and Lampis et al. (2013) report that in families in which a child has an ED, parents tend to control their children’s behavior, seeking perfection in them and imposing high expectations, with the message that they “cannot make a mistake”. At the same time, De la Corte (2016) indicates that an authoritarian style in parents, in particular towards a daughter, is linked to the emergence of EDs.
It was also observed that parents found it difficult to establish clear limits and rules during their children’s childhood and adolescence, and would therefore impose their point of view, make demands and take decisions for them. On this subject, Andrade and Betancourt (2008) indicate the importance of setting clear limits and rules to regulate children’s behavior, rather than using strategies of psychological control, such as physical punishment, denigration, blackmailing and blaming, which interfere with the process of individualization. On the contrary, by using a more democratic child-raising style, parents can facilitate their adolescent children’s process of acquiring self-confidence, differentiation, independence and autonomy (Bazterrica et al., 2012; Dúo et al., 2014), in other words, by promoting the capacity to think, form their own opinions and make decisions for themselves, particularly through questions, exchanges and tolerance for different ideas and choices different from theirs. Healthy development in adolescents creates family environments in which parents accept the separation of their children as a normal part of this stage, when teenagers remain under their parents’ roof yet at the same time, are encouraged to express their own individuality (Carvajal, 1993; De la Corte, 2016; Guelar & Crispo, 2001). Consequently, the onset of an ED in respondents may constitute a means of making decisions about their body and diet, to exert control over their own lives.
Another aspect observed in the participants was the difficulty of expressing and listening to emotions, and solving and addressing problems. Several studies have mentioned that families with a child with an ED experience difficulty in expressing emotions and resolving conflicts (Dring, 2015; Lampis et al., 2009; Minuchin et al., 1978; Ruíz, Vázquez, Mancilla, López & Alvarez, 2009); and even that family members’ inability to communicate with each other, particularly in response to situations of crisis, is related to the onset of EDs (Berge et al., 2011; Brown & Geller, 2006; Dring, 2015; Lampis et al., 2013; Loth et al., 2009). In this study, respondents with an ED said that they did not feel confident enough to express their emotions, tastes or thoughts, for fear of being teased or rejected by their parents. Loth et al. (2009) reported that in order to prevent ED, parents should encourage the expression of feelings within the family, and in particular teach children suitable ways of coping with and handling intense emotions.
One of the contributions of this research project is that it observed parents’ inability to identify and recognize the onset of EDs in their daughters, even when some of them told their parents that they felt very dissatisfied with their weight or figure. This may be associated with the difficulty of resolving conflicts or problems within the family, as a result of which they tend to resort to avoidance, denial or forgetfulness (Bruch, 1982; Mateos-Agut et al., 2014; Minuchin et al., 1978; Selvini-Palazzoli, 1974). Consequently, parents only became aware of their daughter’s ED later, when their body weight was significantly lower or their mood was extremely unfavorable for the family environment. Thus, since dissatisfaction with one’s weight and figure can be regarded as normative aspects in our society, they may go unnoticed, as a result of which it is necessary to increase awareness of EDs.
It has been extensively documented that parents’ negative attitudes towards their daughters’ diet, shape and weight are family aspects related to the onset of an ED (Bäck, 2011; Krug et al., 2013; Meno et al., 2008; Neumark-Sztainer et al., 2010; Quiles et al., 2013; Smart & Tsong, 2014). This was borne out in this study by the fact that participants perceived that their parents were concerned or dissatisfied with their body weight or figure when they were younger, made comparisons, limited the amount of food they were able to eat and set rules about what, how and when to eat.
On the other hand, parents admitted having made affectionate or approving comments to their daughters who were slim, and failed to make these to those who were not slim. However, parents said that they had not realized that their daughters felt they were being compared, singled out or not accepted. This study confirms the findings on the effect of criticism, teasing and conversations on body weight and shape on the development of an ED, and the fact that through this, parents influence the development of this type of disorder in their daughters, as posited by Quiles et al. (2013). Moreover, it has been pointed out those adolescents who are the target of jokes, teasing or comments on their diet, shape and figure risk falling into a vicious cycle of dissatisfaction about their physical appearance, low self-esteem, depressive symptoms and suicide attempts (Neumark-Sztainer, 2006). These negative attitudes promote and foster the idealization of slimness, and undermine body diversity. However, this author stresses the fact that since acceptance of body weight and shape are part of the development of identity in adolescence, care must be taken not to promote body dissatisfaction.
In accordance with the objectives stated for this research, family aspects linked to the development of an ED were identified, and categorized (see Figure 1). The study also attempted to understand the experience of the respondents and the results supported the findings of previous studies indicating the relationship between adolescence and family influence and the development of EDs (Berge et al., 2011; Brown & Geller 2006; Lampis et al., 2013; Loth et al., 2009; Quiles et al., 2013). The findings of this study provide information that could be used to develop prevention programs targeting Mexican parents of teenagers at risk of developing an ED. On the other hand, however, the limitations of this study include possible biases in the respondents’ memory in reconstructing previous experiences, which may be influenced by the psychotherapeutic process and treatment they are undergoing, or simply by the passage of time. Lastly, it is suggested that future research could use quantitative techniques to complement the results of this study, such as statistical correlation, to obtain a more accurate picture of which parenting practices have a significant impact on risking eating behaviors and ED symptoms, and study the topic in greater depth, and to include male ED patients.
