The role of general family environment and sexual and physical abuse in the origins of eating disorders

Eating disorder in children: Impact on quality of life, with a spotlight on autism spectrum disorder

Eating behavior, which includes eating habits and preferences, frequency of eating, and other features related to diet, is a major characteristic not only of a person's nutritional status, but also of health in general. In recent years, the prevalence of eating disorders in children has tended to increase; they also require cross-system approaches in diagnosis by a variety of specialists and correction requires appropriate selection of optimal methods. Maladaptive eating attitudes formed at an early age can contribute to the formation of eating disorders, which can lead to or worsen various neuropsychiatric diseases, digestive diseases, and other related conditions. In children with autism spectrum disorder (ASD), eating disorders often appear earlier than other major symptoms of the condition. However, the clinical manifestations of eating disorders in children with ASD are varied and differ in severity and duration, whereas these disorders in neurotypical children might present as short-lived and may not lead to serious consequences. Nevertheless, cases of progressive eating disorders accompanied by a child presenting as under- or overweight and/or with macronutrient and micronutrient deficiencies cannot be excluded. Given the high prevalence of eating disorders in children, many researchers have highlighted the lack of a valid and universally accepted instruments to assess atypical eating behaviors in this population. Therefore, in this review, we wanted to highlight the problems and causes of eating disorders in children, and also to analyze the existing approaches to the validation of these problems, taking into account the existing behavioral features in children with ASD.

Urinary free cortisol and childhood maltreatments in eating disorder patients: New evidence for an ecophenotype subgroup

Introduction

Increasing neurobiological evidence has suggested the presence of a specific ecophenotype in people with eating disorders (EDs) linked to early maltreatment. Urinary‐free cortisol could strengthen the data and show specific relationships between maltreated subtypes and the hormonal profiles of patients with EDs. This study aims to evaluate the presence of different urinary cortisol in drug‐free patients in the acute phase of the disorder and its relationship with childhood maltreatment.

Methods

A sample of 78 female patients with ED is included in the study. Childhood maltreatment history and 24‐h urinary free cortisol (24‐h UFC) are evaluated at a specialised ED ward admission.

Results

Patients with a maltreatment history show more blunted 24‐h UFC levels than peers without childhood maltreatment (p = 0.001). Regression analysis showed that child abuse is a predictor of the reduction of 24‐h UFC (p < 0.001), with physical abuse (p = 0.011) and sexual abuse (p = 0.050) that could have a more specific impact than other maltreatment subtypes.

Discussion

Childhood maltreatment should be evaluated in ED patients due to its biological impact on the hormonal stress axis, which could impair the ability of patients to respond to standardized ED treatment.

Eating disorder patients with history of maltreatment showed a reduced 24‐h urinary free cortisol.

New data support the evidence about the presence of an ecophenotype ED subgroup.

Reduced 24‐h urinary free cortisol is significantly correlated with child abuses.

Significance, Nature, and Direction of the Association Between Child Sexual Abuse and Conduct Disorder: A Systematic Review

To elucidate the significance, nature, and direction of the potential relationship between child sexual abuse and conduct disorder, all the pertinent studies were reviewed. Ten databases were searched. Blind assessments of study eligibility and quality were performed by two independent researchers. Thirty-six studies including 185,358 participants and meeting minimum quality criteria that were enough to ensure objectivity and to not invalidate results were analyzed. Across the majority of studies, conduct disorder was significantly and directly related to child sexual abuse, especially repeated sexual molestation and abuse involving penetration, even after controlling for various sociodemographic, family, and clinical variables. The association between child sexual abuse and conduct disorder was not confounded by other risk factors, such as gender, socioeconomic status, school achievement, substance problems, physical abuse, parental antisocial behavior or substance problems, parent-child relationships, and family disruption, conflict, or violence. Evidence for a significant interactive effect between child sexual abuse and monoamine oxidase A gene on conduct disorder was scant. Early sexual abuse might predispose to the subsequent onset of conduct disorder which, in turn, may lead to further sexual victimization through association with sexually abusive peers or involvement in dangerous situations or sexual survival strategies.

Maternal and family factors and child eating pathology: risk and protective relationships

BACKGROUND

Previous studies have found associations between maternal and family factors and child eating disorder symptoms. However, it is not clear whether family factors predict eating disorder symptoms specifically, or relate to more general child psychopathology, of which eating disorder symptoms may be one component. This study aimed to identify maternal and family factors that may predict increases or decreases in child eating disorder symptoms over time, accounting for children's body mass index z-scores and levels of general psychological distress.

METHODS

Participants were 221 mother-child dyads from the Childhood Growth and Development Study, a prospective cohort study in Western Australia. Participants were assessed at baseline, 1-year follow-up and 2-year follow-up using interview and self-report measures. Children had a mean age of 10 years at baseline and 46% were male. Linear mixed models and generalised estimating equations were used to identify predictors of children's eating disorder symptoms, with outcome variables including a global index of eating disorder psychopathology, levels of dietary restraint, levels of emotional eating, and the presence of loss of control ('binge') eating.

RESULTS

Children of mothers with a current or past eating disorder reported significantly higher levels of global eating disorder symptoms and emotional eating than other children, and mothers with a current or past eating disorder reported significantly more concern about their children's weight than other mothers. Maternal concern about child weight, rather than maternal eating disorder symptoms, was significant in predicting child eating disorder symptoms over time. Family exposure to stress and low maternal education were additional risk factors for eating disorder symptoms, whilst child-reported family satisfaction was a protective factor.

CONCLUSIONS

After adjusting for relevant confounding variables, maternal concern about child weight, children's level of family satisfaction, family exposure to stress, and maternal education are unique predictors of child eating disorder symptoms.

Helplessness, mastery and the development of eating disorders: exploring the links between vulnerability and precipitating factors

BACKGROUND

Helplessness and mastery in childhood and in response to the events that trigger onset are implicated in the development of eating disorders. However, no studies have yet explored how these are linked and whether the effects are additive or mediated.

METHOD

Semi-structured interviews (Childhood Experience of Care and Abuse; Life Events and Difficulties Schedule; Coping Strategies Interview) were used to assess helplessness and mastery in childhood and in response to a provoking agent in 15 eating disordered and 19 non-eating disordered women.

RESULTS

Helplessness and mastery in childhood were related to helplessness and mastery in response to the events and difficulties that triggered onset of the eating disorder. However, only the presence of helplessness and the lack of mastery in response to this provoking agent predicted onset.

CONCLUSION

Helplessness and mastery are vulnerability and protective factors but only in those women who develop an eating disorder in the context of later life events. It is suggested that helplessness and mastery in childhood act via their influence on the adequacy of coping in response to later life events.

Attitudes towards emotional expression mediate the relationship between childhood invalidation and adult eating concern

Previous research has suggested that invalidating childhood environments are positively related to the symptoms of eating disorders. However, it is unclear how childhood environments might impact upon the development of eating disorder symptoms. This study examined the relationship between parental invalidation and eating disorder-related attitudes in a nonclinical sample and tested the mediating effect of attitudes towards emotional expression. Two hundred women, with a mean age of 21 years, completed measures of invalidating childhood environments, attitudes towards emotional expression, and eating pathology. Eating concerns were positively associated with recollections of an invalidating parental environment. The belief that the expression of emotions is a sign of weakness fully mediated the relationship between childhood maternal invalidation and adult eating concern. Following replication and extension to a clinical sample, these results suggest that targeting the individual's attitude towards emotional expression might reduce eating attitudes among women who have experienced an invalidating childhood environment.

Trait-defined eating-disorder subtypes and history of childhood abuse

OBJECTIVE

In participants with eating disorders (EDs), prior physical or sexual abuse has been associated with increased likelihood of impulsivity and affective instability. However, previous studies among participants with eating disorders have not systematically explored relationships between empirically derived, personality-trait-based classes, on the one hand, and likelihood of exposure to either childhood sexual or physical abuse, on the other.

METHOD

We assessed multiple psychopathological traits, eating symptoms, and history of abuse in 185 women with an ED and 93 with no ED.

RESULTS

A latent class analysis, conducted using psychopathological-trait measures, yielded latent classes of participants with eating disorders fitting the descriptors "dissocial/impulsive," "inhibited/compulsive," and "low psychopathology." ED was generally associated with increased risk of childhood sexual abuse, but the dissocial/impulsive characteristic corresponded with a unique likelihood of physical abuse and especially high rates of sexual abuse.

DISCUSSION

Observed associations between different forms of childhood abuse and trait-defined ED variants help inform models on the development of eating disorders and of psychopathological traits that often accompany them.

The influence of puberty onset, body mass index, and pressure to be thin on disordered eating behaviors in children and adolescents

The main objective of this study is to verify the hypothesis that pubertal development, obesity, body satisfaction, as well as family and peer influences predict unhealthy eating habits in children and adolescents. A randomized stratified sample of young Quebecers aged 9, 13, and 16 years on March 31, 1999 [608 children aged of 9 years (325 girls and 283 boys) and 662 adolescents aged of 13 and 16 years (349 girls and 313 boys)] were used. Children's weight, height, and Body Mass Index (BMI) were recorded. Questionnaires were administered to children and a parent (usually the mother). Among 9-year-old children, this study found that weight loss or weight control behaviors were predicted mainly by the onset of puberty, lower maternal abusive control, and the level of peer pressure. Among adolescents, mother's BMI, income, peer pressure, and negative comments about the child's weight most strongly predicted behaviors to control weight, strategies to lose weight and the frequency of such behaviors. The findings suggest that both parents and children need to understand the impact of comments on a child's behavior.

Impulsivity and personality variables in adolescents with eating disorders

Impulsivity among individuals with eating disorders (EDs) is associated with severe comorbidities and poor treatment outcome. However, research investigating the construct of impulsivity in EDs is limited. The objectives of the present study were to characterize multiple dimensions of impulsivity in adolescents with EDs; determine if differences in impulsivity were associated with ED diagnosis and/or broader personality traits; and explore the relationship between impulsivity and etiologically significant variables. Experienced clinicians from a practice-research network provided data on ED symptoms, impulsive characteristics, personality pathology, The Diagnostic and Statistical Manual of Mental Disorders comorbidity, and family and developmental history for 120 adolescent patients with EDs. Three distinct types of impulsivity were identified: general, acting out, and aggressive/destructive. The impulsivity types showed specific relationships to ED diagnosis, broader personality factors, individual histories of adverse (traumatic) events, and family histories of externalizing disorders, supporting the importance of taking, assessing, and addressing impulsivity in ED research and treatment.

Invalidating childhood environments in anorexia and bulimia nervosa

OBJECTIVE

This study examined the relationship between an invalidating childhood environment and eating pathology, including diagnoses, eating attitudes and eating behaviours.

METHOD

Fifty-eight eating-disordered patients completed a measure of invalidating childhood environments, and a standardised measure of eating pathology.

RESULTS

Patients with bulimia nervosa scored higher on levels of paternal invalidation than those with anorexia nervosa. There were no associations at the attitudinal level, but some behaviours were related to perceived parental style. Self-induced vomiting was associated with paternal invalidation, while those who experienced an invalidating mother were less likely to report binge-eating. Those who exercised excessively were more likely to have experienced a family style in which the focus is on remaining in control of one's emotions, success and achievement.

DISCUSSION

Invalidating childhood environment was related to eating psychopathology in a clinical population - particularly the presence or absence of some behaviours. Implications for treatment are considered.

Does the level of expressed emotion (LEE) questionnaire have the same factor structure for adolescents as it has for adults?

BACKGROUND

The level of expressed emotion (LEE) is a four-factor questionnaire that measures expressed emotion (EE) as perceived by the recipient. These factors are: perceived lack of emotional support, perceived intrusiveness, perceived irritation, and perceive criticism. The four factors of the LEE has previously been found to be related to psychological disorders and has good psychometric properties for adults. However, it has not previously been studied in adolescent populations.

METHODS

A total of 311 adolescents participated in this study. Using structural equation modeling, confirmatory factor analyses were conducted to examine if the LEE also had the same four-factor structure for adolescents as it does for adults.

RESULTS

The confirmatory factor analyses demonstrated that the LEE's four-factor structure also applied to adolescents. The internal consistency of the scales were good and all the inter-correlations between the scales were significant. Additionally, the factors were significantly correlated to adolescent depressive and anxiety symptom score dimensions.

CONCLUSION

These findings seem to indicate that the LEE may be a good instrument in the measurement of adolescents perceived EE.

Eating disorders and body image in Spanish and Mexican female adolescents

OBJECTIVE

To compare the prevalence of eating disorders (ED), socio-cultural risk factors, and body image characteristics in two populations of female adolescents, one Mexican and one Spanish, from similar socio-economic backgrounds.

METHOD

A total of 467 Spanish and 329 Mexican girls aged from 11-12 to 17-18 years were assessed using the Eating Attitude Test-26 (EAT-26), the CETCA (Eating Disorders Assessment Questionnaire), the CIMEC (Questionnaire on Influences on Body Shape Model), and a survey of socio-demographic and risk factors produced for this study.

RESULTS

One out of four subjects showed a significant risk of an eating disorder and 6-7% probably already had one. No significant differences were found between the two samples. Significant differences were found in risk behaviors: more Spanish girls reported body dissatisfaction and binging; more Mexican girls had a history of psychiatric and psychological treatment, pressure from parents and friends to lose weight, dieting, physical activity and vomiting to lose weight, and a history of greater weight loss. In both the groups around 50% of subjects wanted to increase the size of their breasts. However, significantly more Mexican girls desired thinner arms and narrower shoulders and back, and more Spanish girls wanted thinner hips, buttocks, and legs, parts of the body that many Mexicans wanted to increase.

CONCLUSIONS

Risk behaviors and the ideal body models of these Spanish and Mexican adolescent girls varied significantly, indicating major socio-cultural differences. However, the prevalence of ED was similar. Further research should aim to clarify whether the similarities found between this Spanish sample and a Mexican sample taken from an upper-middle class urban environment, a minority that is unrepresentative of the general population, are also observed in samples from other sectors of Mexican society.

Why do adolescents with bulimia nervosa choose not to involve their parents in treatment?

BACKGROUND

Although the use of family therapy for adolescents with anorexia nervosa is well established, there has been limited research into the efficacy of family therapy in adolescents with bulimia nervosa (BN). No previous research has investigated why individuals with BN do or do not involve their parents in treatment. This is an exploratory study aimed at determining whether there are any differences between these individuals in terms of eating disorder symptomatology, psychopathology, familial risk factors, patients' perception of parental expressed emotion (EE) and family functioning.

METHODS

Participants were 85 adolescents with BN or Eating Disorder Not Otherwise Specified, recruited to a randomised controlled evaluation of the cost-effectiveness of cognitive-behavioural guided self-care vs. family therapy. Participants were interviewed regarding the history of their eating disorder and completed self-report measures.

RESULTS

Patients who did not involve their parents in treatment were significantly older, had more chronic eating disorder symptoms, exhibited more co-morbid and impulsive behaviours and rated their mothers higher in EE. However, they did not have more severe eating disorder symptomatology.

CONCLUSIONS

These preliminary findings, although in need of replication with a larger sample and limited by the attrition rate in some of the self-report measures, indicate that patients who did not involve their parents in treatment may perceive their mothers as having a more blaming and negative attitude towards the patient's illness. Public awareness about BN needs to be raised, focusing on reducing the stigma and negative views attached to this illness.

Mothers' expressed emotion towards children with and without intellectual disabilities

OBJECTIVES

To identify factors associated with maternal expressed emotion (EE) towards their child with intellectual disability (ID).

DESIGN AND METHOD

A total of 33 mothers who had a child with ID and at least one child without disabilities between the ages of 4 and 14 years participated in the study. Mothers completed self-assessment questionnaires which addressed their sense of parenting competence, beliefs about child-rearing practices, and their reports of behavioural and emotional problems of their child with ID. Telephone interviews were conducted to assess maternal EE towards the child with ID and towards a sibling using the Five Minute Speech Sample (FMSS; Magana et al. 1986), and also to assess the adaptive behaviour of the child with ID using the Vineland Adaptive Behaviour Scale (VABS; Sparrow et al. 1984).

RESULTS

Mothers with high EE towards their child with ID were more satisfied with their parenting ability, and their children had more behaviour problems. Analysis of differential maternal parenting, through comparisons of EE towards their two children, showed that mothers were more negative towards their child with ID for all domains of the FMSS except dissatisfaction.

CONCLUSIONS

A small number of factors associated with maternal EE towards children with ID were identified. Differences in maternal EE towards their child with ID and their other child suggest that EE is child-driven rather than a general maternal characteristic. Implications of the data for future research are discussed.

Parental bonding and bulimic psychopathology: the mediating role of mistrust/abuse beliefs

OBJECTIVE

To determine whether the previously reported relationship between parental bonding and bulimic psychopathology is mediated by the development of unhealthy core beliefs.

METHOD

One hundred and two nonclinical women completed the Parental Bonding Instrument, the short form of the Young Schema Questionnaire, and the Bulimic Investigatory Test, Edinburgh.

RESULTS

Mistrust/abuse beliefs were found to be a partial mediator in the relationship between paternal overprotection and the severity of bulimic attitudes.

CONCLUSIONS

The findings suggest that the development of mistrust/abuse beliefs is important in determining the effect that paternal overprotection has on bulimic attitudes.

[Subjective family image in anorexia nervosa and bulimia nervosa in adolescence: a controlled study]

OBJECTIVES

The family environments of patients with eating disorders have been studied extensively in recent decades. The "Subjective Family Image Test" is an instrument developed especially to measure differential perceptions by family members. Assessments of subjective family image in families of adolescents by means of this test have been carried out in only a few samples.

METHODS

We aimed first to investigate subjective perceptions by adolescents of their family relations in a larger clinical sample of female adolescents (n = 118) suffering from anorexia nervosa of either subtype or from bulimia nervosa and to compare these perceptions with those of healthy controls (n = 96). Second we investigated intra-familial differences in perception.

RESULTS

The main findings were that bulimia nervosa patients perceived lower individual autonomy and lower emotional connectedness than all other groups, the adolescents with bulimia perceived significantly lower autonomy and emotional connectedness within the family than their fathers, and the restrictive anorexia nervosa patients perceived higher connectedness than their fathers. The relevance of these findings for understanding family dynamics are discussed.

Genetic relationships between personality and eating attitudes and behaviors

Genetic and environmental factors underlying relationships between personality traits and disordered eating were examined in 256 female adolescent twin pairs (166 monozygotic, 90 dizygotic). Eating behaviors were assessed with the Total Score, Body Dissatisfaction, Weight Preoccupation, Binge Eating, and Compensatory Behavior subscales from the Minnesota Eating Disorders Inventory (M-EDI; K. L. Klump, M. McGue, & W. G. Iacono, 2000). Personality characteristics were assessed with the Negative Emotionality, Positive Emotionality, and Constraint scales from the Multidimensional Personality Questionnaire (MPQ; A. Tellegen, 1982). Model-fitting analyses indicated that although genetic factors were more likely to contribute to MPQ and M-EDI phenotypic associations than environmental factors, shared genetic variance between the 2 phenotypes was limited. MPQ personality characteristics may represent only some of several genetic risk factors for eating pathology.

Does environment matter? A review of nonshared environment and eating disorders

OBJECTIVE

Nonshared environmental influences are experiences that are unique to siblings reared in the same family. We review studies highlighting the importance of nonshared factors for the development of eating disorders and suggest areas for future research.

METHODS

Findings from behavioral genetic studies of eating disorders as well as methodological issues are reviewed.

RESULTS

Twin studies suggest that approximately 17%-46% of the variance in both anorexia nervosa (AN) and bulimia nervosa (BN) can be accounted for by nonshared environmental factors. Studies directly examining these influences are scarce, although initial data indicate that differential paternal relationships, body weight teasing, peer group experiences, and life events may account for the development of eating pathology in one sibling versus another.

DISCUSSION

Additional research is needed to identify specific nonshared environmental influences on eating disorders such as differential parental and sibling treatment, disparate peer group characteristics, and differential experience of life events such as physical and sexual abuse.