Family Functioning in Adolescents with Binge-Eating Disorder

A systematic review of eating disorders and family functioning

The purpose of the current review was to address four questions: 1) Are there differences in family functioning or family environment among patients with different eating disorder (ED) diagnoses? 2) Are there differences in the perception of family functioning or family environment among different family members? 3) Is family functioning or family environment related to ED symptomatology? 4) Does family functioning or family environment change as a result of ED treatment? and 4a) If so, does this impact ED treatment outcome? Although most studies found no differences among ED diagnostic groups, those that did generally found worse family functioning among those with binge/purge symptoms than among those with the restricting subtype of anorexia nervosa. Differences in perceptions of family functioning among family members were found, with patients generally reporting worse functioning than their parents. Worse family functioning was generally found to be related to worse ED symptoms. The variety of treatment approaches and different assessments of outcome made it somewhat unclear whether family functioning consistently improves with ED treatment. More research is needed on family functioning and EDs, particularly in understudied groups such as males, and those with ED diagnoses other than anorexia nervosa or bulimia nervosa.

Attachment-Based Family Therapy to Improve Family Functioning in Adolescent Binge-Spectrum Eating Disorders: An Initial Evaluation Via Case Series Design

Binge-spectrum eating disorders (EDs; bulimia nervosa, binge eating disorder) often develop during adolescence and are associated with serious psychological and physical consequences. Current treatments for adolescents are highly behavioral in nature and while efficacious, many patients do not reach remission indicating that current treatments fail to target a key maintenance factor for EDs. One potential maintenance factor is poor family functioning (FF). In particular, high family conflict (e.g., arguing, critical comments) and low family cohesion (e.g., warmth, support) are known to maintain ED behaviors. Poor FF can (1) cause or exacerbate an adolescent's use of ED behaviors to cope with life stress and/or (2) inhibit parents from being a resource to adolescents during ED treatment. Attachment-Based Family Therapy (ABFT) is specifically designed to improve FF, and thus may be a promising adjunct to behavioral ED intervention strategies. ABFT, however, has not been tested in adolescents with binge-spectrum EDs. Thus, the current study is the first to evaluate a 16-week adapted ABFT treatment for adolescents with EDs (N = 8, Mage = 16.00, 71.43% female, 71.43% White) fusing together behavioral treatment for EDs with ABFT for highest possible impact. Eight families were treated in an open pilot trial to examine treatment feasibility, acceptability, and preliminary efficacy on FF and eating pathology. Overall, findings were promising. ABFT + B treatment was feasible and acceptable and showed preliminary evidence that it could improve FF and ED behaviors. Future research will test this intervention in a larger sample and further examine the role of FF in maintaining ED symptoms.

Interactions between emotions and eating behaviors: Main issues, neuroimaging contributions, and innovative preventive or corrective strategies

Emotional eating is commonly defined as the tendency to (over)eat in response to emotion. Insofar as it involves the (over)consumption of high-calorie palatable foods, emotional eating is a maladaptive behavior that can lead to eating disorders, and ultimately to metabolic disorders and obesity. Emotional eating is associated with eating disorder subtypes and with abnormalities in emotion processing at a behavioral level. However, not enough is known about the neural pathways involved in both emotion processing and food intake. In this review, we provide an overview of recent neuroimaging studies, highlighting the brain correlates between emotions and eating behavior that may be involved in emotional eating. Interaction between neural and neuro-endocrine pathways (HPA axis) may be involved. In addition to behavioral interventions, there is a need for a holistic approach encompassing both neural and physiological levels to prevent emotional eating. Based on recent imaging, this review indicates that more attention should be paid to prefrontal areas, the insular and orbitofrontal cortices, and reward pathways, in addition to regions that play a major role in both the cognitive control of emotions and eating behavior. Identifying these brain regions could allow for neuromodulation interventions, including neurofeedback training, which deserves further investigation.

Extending the Biopsychosocial Conceptualisation of Chronic Post Surgical Pain in Children and Adolescents: The Family Systems Perspective

A substantial number of children and adolescents undergoing surgical procedures, as many as 40% in some estimates, will go on to develop chronic postsurgical pain (CPSP). Because of the significant negative impact of CPSP on social and emotional milestones, as well as the child's quality of life, it is important to identify modifiable factors that are associated with the onset and maintenance of the condition. Research has demonstrated that parent factors can play a role in pediatric chronic pain; however, there has been little examination of parent and family influences on the transition to CPSP. Family systems theories, which consider the influence of the family unit overall on the behavior of individuals members, have been applied to the eating disorders literature for decades. This narrative review proposes a novel application of family systems theory to pediatric CPSP and, in particular, highlights the role that parental dyadic factors may play in the development and maintenance of persistent pain following surgery in children and adolescents.

Identifying Loss of Control Eating within Childhood Obesity: The Importance of Family Environment and Child Psychological Distress

This study aims to examine the differences in family environment, psychological distress, and disordered eating symptomatology between children classified by weight status with or without loss of control (LOC) eating and to test a model of the role of emotional regulation of LOC eating based on a dysfunctional family environment. A cross-sectional study was conducted among 239 families. The assessment measured family expressed emotion, family adaptability and cohesion, child levels of depression and anxiety, body esteem, and disordered eating attitudes. The assessment was carried out in primary care centers and primary schools. Child body mass index (BMI) was associated with higher expressed emotion, psychological distress, and disordered eating symptomatology. Children with obesity and LOC presented higher BMI, poorer body esteem, and more disordered eating attitudes than children without LOC. Children with overweight/obesity, both with or without LOC, exhibited higher psychological distress and emotional overinvolvement than normal-weight children. A partial mediation of depression or anxiety and disordered eating attitudes between expressed emotion and LOC was found. Findings support that children with overweight/obesity show more family and psychological distress. Body esteem issues and disordered eating attitudes could alert the presence of LOC in children with obesity. The function of LOC might be to cope with psychological distress that may appear in a dysfunctional family environment.

Binge eating and binge drinking behaviors: the role of family functioning

Binge eating and binge drinking are two of the most common health-risk behaviors among young people showing to frequently co-occur in nonclinical samples of adolescent boys and girls. The present study examined the role of different dimensions of family functioning in binge behaviors among adolescents. One thousand and twenty young to late adolescents (507 girls and 517 boys) with ages ranging from 16 to 22 years participated in the study and completed a survey of self-report measures. Our findings showed that adolescents who binge eat and drink and adolescents who only binge eat perceived a lower quality of family functioning with lower levels of cohesion, flexibility, communication, satisfaction and higher degree of disengagement compared to adolescents who do not binge and adolescents who only binge drink. Only adolescents who engage in both binge behaviors reported higher levels of chaotic style compared to other binge groups. Furthermore, living in families poorly flexible, highly disengaged and with communication problems among members resulted as risk factors for binge eating behavior. Results suggest the importance for prevention programs to be based on an integrated approach focused on improving family environment such as the ability in changing family structure to deal effectively with developmental problems and defining clear home rules adolescents may stand on.

Family mealtime negativity and adolescent binge-eating: A replication and extension study in a community sample

OBJECTIVE

To explore differences in family mealtime characteristics and family mealtime emotions among adolescents who report engaging in binge-eating in comparison to those who do not.

METHOD

Adolescents (N = 495) recruited from UK schools/colleges reported on their family mealtime frequency and atmosphere, family mealtime emotions, anxiety, depression and eating psychopathology.

RESULTS

No significant differences were found between adolescents who reported binge-eating (n = 32 boys; n = 82 girls) and those who did not (n = 196 boys; n = 185 girls) on family mealtime frequency or mealtime atmosphere scores. However, boys and girls who binge-eat reported significantly lower levels of positive family mealtime emotions and significantly higher levels of family mealtime anxiety and anger (girls only), compared with their peers who did not report binge-eating.

DISCUSSION

Adolescents who binge-eat experience significantly greater negative emotional responses to family mealtimes than their peers. Further research should explore why these experiences are more negative, including broader familial factors and interactions.

Family functioning, moods, and binge eating among urban adolescents

This study builds upon prior research on associations between moods, family functioning, and binge eating, using ecological momentary assessment to examine moderating effects of family functioning on associations between moods and binge eating. This study was conducted among a nonclinical sample of urban adolescents. Family functioning was assessed using five constructs adopted from the FACES-IV measure: 'family cohesion,' 'family flexibility' 'family communication,' 'family satisfaction,' and 'family balance.' Mood data was gathered using 13 items from a daily affect scale. Binge eating was assessed using two subscales from the Eating Disorder Diagnostic Scale-binge eating associated with 'embarrassment' (BE1), and binge eating associated with a sense of 'loss of control' (BE2). A multilevel modeling approach was employed to examine how associations between momentary moods and binge eating behaviors were moderated by family functioning. Results indicated that measures of negative affect, stress/frustration, and tiredness/boredom were significantly and positively associated with two measures of binge eating (BE1 and BE2; p values ≤ 0.05), and that multiple factors of family functioning buffered the positive predictive effects of moods on binge eating. Findings indicate the importance of inclusion of family functioning in the development of eating behavior interventions for adolescents.

Perceived family functioning among adolescents with and without loss of control eating

Youth with loss of control eating (LOC) have poorer social relationships than youth without LOC. However, perceived family functioning among youth reporting LOC is relatively unexplored. We examined perceived family functioning among 990 twins (age = 17.47 ± 0.71 years, 53% female) from the Colorado Center for Antisocial Drug Dependence with (n = 158) and without (n = 832) LOC. LOC was assessed with one binary item. Associations between family functioning and LOC were examined using general linear models that accounted for dependence in twin data. Girls with greater family conflict had higher odds of endorsing LOC (p = .02), but not after accounting for depressive symptoms (p = .26). Further analysis indicated that depressive symptoms mediated the association between LOC and family conflict (p = .04). This finding is consistent with an interpersonal model, which proposes that interpersonal difficulties lead to negative emotional states, which promotes LOC as a method of coping with negative affect. Family cohesion and expressiveness were not associated with LOC in girls, and none of the family functioning variables were associated with LOC in boys (ps > .05). Future studies are needed to clarify these relations and to determine any relevant treatment indications.

Perceived Family Functioning in Relation to Energy Intake in Adolescent Girls with Loss of Control Eating

Family functioning is hypothesized to influence the development, maintenance, and treatment of obesity and eating disorders. However, there are limited data examining family functioning in relation to energy intake in the laboratory among youth at high-risk for eating disorders and excess weight gain. Therefore, we examined the relationship between perceived family functioning and energy intake during a laboratory test meal designed to model a binge episode. We performed hierarchical multiple regression analyses among 108 adolescent girls in an excess weight gain prevention trial. Participants were at high-risk for eating disorders and excess weight gain due to reports of loss of control eating (LOC) and high body mass index (BMI). Participants completed the Family Adaptability and Cohesion Scale III to assess family adaptability and cohesion. Following an overnight fast, girls consumed lunch from a laboratory test meal. Poorer family adaptability, but not cohesion, was associated with lower percentage of total energy intake from protein and greater percentage of total energy intake from carbohydrates. Neither adaptability nor cohesion were significantly associated with total intake. We conclude that among girls with LOC eating and high BMI, poor reported family adaptability is associated with greater consumption of obesity-promoting macronutrients during binge episodes. Directionality and temporality of this association between unhealthy consumption and family rigidity requires further study.

Family profiles in eating disorders: family functioning and psychopathology

Research has studied family functioning in families of patients suffering from eating disorders (EDs), particularly investigating the associations between mothers’ and daughters’ psychopathological symptoms, but limited studies have examined whether there are specific maladaptive psychological profiles characterizing the family as a whole when it includes adolescents with anorexia nervosa (AN), bulimia nervosa (BN), and binge eating disorder (BED). Through the collaboration of a network of public and private consultants, we recruited n=181 adolescents diagnosed for EDs (n=61 with AN, n=60 with BN, and n=60 with BEDs) and their parents. Mothers, fathers, and youths were assessed through a self-report measure evaluating family functioning, and adolescents completed a self-report questionnaire assessing psycho-pathological symptoms. Results showed specific family functioning and psychopathological profiles based on adolescents’ diagnosis. Regression analyses also showed that family functioning characterized by rigidity predicted higher psychopathological symptoms. Our study underlines the importance of involving all members of the family in assessment and intervention programs when adolescent offspring suffer from EDs.

Relationships Between Self-Reported and Observed Parenting Behaviour, Adolescent Disordered Eating Attitudes and Behaviours, and the 5-HTTLPR Polymorphism: Data From the Australian Temperament Project

This study examined whether self-reported and observationally measured parental behaviours were associated with disordered eating, and investigated possible moderation by a serotonin-transporter polymorphism (5-HTTLPR). Study 1 included 650 adolescents from the Australian Temperament Project who completed the Eating Disorder Inventory-2 Drive for Thinness and Bulimia scales at 15/16 years and were genotyped for 5-HTTLPR. Parents completed an Australian Temperament Project-devised measure of parental warmth and harsh punishment. Study 2 included a subgroup of 304 participants who also engaged in a video-recorded family interaction, with observed parental warmth and hostility coded by the Iowa Family Interaction Rating Scale. Greater self-reported parental warmth was associated with lower bulimia scores. Conversely, observationally measured parental warmth was associated with lower drive for thinness, but not bulimia. Self-reported parental harsh punishment was associated with bulimia only, with observed parental hostility associated with neither outcome. 5-HTTLPR genotype did not moderate the relationship between parent behaviours and adolescent disordered eating. Copyright © 2017 John Wiley & Sons, Ltd and Eating Disorders Association.