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Clinical Child and Family Psychology Review (CCFP) pp426-ccfp-369382 February 26, 2002 18:8 Style file version Nov. 07, 2000

Clinical Child and Family Psychology Review, Vol. 5, No. 1, March 2002 (°
C 2002)

The Children of Mothers With Eating Disorders

Priti Patel,1 Rebecca Wheatcroft,2 Rebecca J. Park,3,4 and Alan Stein5,6

There is good evidence that children of parents with psychological disorders are themselves
at increased risk of disturbances in their development. Although there has been considerable
research on a variety of disorders such as depression and alcohol, research on the children of
parents with eating disorders has been relatively recent. This paper aims to review the evidence
and covers a number of areas, including genetic factors, pregnancy, the perinatal and postpar-
tum period, infancy, and the early years of life, focusing on feeding and mealtimes, general
parenting functions, and growth. This is followed by a consideration of psychopathology in
the children, parental attitudes to children’s weight and shape, and adolescence. What is clear
is that although there are numerous case reports and case series, the number of systematic
controlled studies is relatively small, and almost nothing has been written about the children
of fathers with eating disorders. What is evident from the available evidence is that children of
mothers with eating disorders are at increased risk of disturbance, but that the risk depends on
a variety of factors, and that difficulties in the children are far from invariable. The paper con-
cludes by summarizing five broad categories of putative mechanisms, based on the evidence
to date, by which eating disturbance in parents can influence child development.
KEY WORDS: eating disorder; intergenerational transmission; feeding; body shape; growth.

Since the 1960s, studies have established that chil-
dren of parents with psychological disturbance are at
risk of disturbance themselves (Garmezy & Masten,
1994; Richman, Graham, & Stevenson, 1982; Rutter,
1989; Rutter & Quinton, 1984). Furthermore the dis-
turbance in children may persist well after remission
of parental disorder and this has been established
particularly in conditions such as postnatal depres-
sion (Barnes & Stein, 2000; Murray & Cooper, 1996;
1 Tavistock Centre, London.
2 Leopold
Muller Department of Child and Family Mental Health,
Royal Free and University College Medical School, Royal Free
Campus, London.
3 Developmental Psychiatry Section, Department of Psychiatry,
University of Cambridge, Cambridge.
4 Bedford and Luton Community NHS Trust, Cambridge.
5 Section of Child and Adolescent Psychiatry, Department of Psy-
chiatry, Warneford Hospital, University of Oxford, Oxford.
6 Address all correspondence to Alan Stein, Department of Psychi-
atry, Warneford Hospital, University of Oxford, Oxford OX3 7JX,
United Kingdom; e-mail: alan.stein@psych.ox.ac.uk.
Rutter, 1989). Eating disorders have been the subject
of a great deal of research. However, eating disor-
ders in parents and the implications for their children
have only been a relatively recent research focus. It is
the aim of this review to examine the literature to
identify what is known on the subject; in the con-
cluding section we suggest possible mechanisms by
which eating disorders influence parenting and child
development.
It is notable that almost all the research to date
in this area has concerned mothers with eating dis-
orders. Very few studies have examined fathers with
eating disorders or included the roles and attitudes of
fathers in exacerbating, ameliorating, or acting inde-
pendently of the possible influences of a mother who
has an eating disorder. This is an area that requires
research attention. There is much research on family
functioning in adolescents with eating disorders but
it has not generally dealt with the issue of parents
with eating disorders and their influence on the chil-
dren, and was judged to be not within the scope of this
review.

1
1096-4037/02/0300-0001/0 °
C 2002 Plenum Publishing Corporation
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Clinical Child and Family Psychology Review (CCFP) pp426-ccfp-369382 February 26, 2002
2 Patel, Wheatcroft, Park, and Stein
EATING DISORDERS: PREVALENCE
AND DIAGNOSTIC CRITERIA
Eating disorders are a common source of psy-
chiatric morbidity in women of childbearing age.
Epidemiological studies estimate the prevalence of
anorexia nervosa and bulimia nervosa to be 1–2% in
women aged 16–40 years (Fairburn & Beglin, 1990).
This rate increases to 4% when the full spectrum of
the disorder is considered (Hoek, 1993). The onset of
eating disorders is usually in adolescence and there
is some evidence that it is on the increase (Treasure,
Troop, & Ward, 1996), affecting women from wider
socioeconomic and ethnic backgrounds than previ-
ously considered.
The main criteria for a DSM-IV diagnosis of
anorexia nervosa (AN) are the following: a body
weight 15% below expected standard (Body Mass
Index (BMI) < 17.5); an intense fear of weight gain;
distorted body image and amenorrhoea in women.
Onset is usually in adolescence and generally be-
gins with efforts at dieting that then become ex-
treme. Bulimia nervosa (BN) was first described by
Russell (1979) as an “ominous variant” of anorexia
nervosa. The central feature of this disorder is recur-
rent episodes of uncontrolled binge eating alongside
extreme compensatory measures to control weight
gain, such as vomiting, purging, and exercise. These
individuals also have a morbid fear of fatness and eval-
uate themselves by body shape and weight. Women
with BN are usually of normal weight and have regu-
lar menstrual cycles. Comorbid depressive symptoms
are common and the disorder tends to run a chronic
course (Herzog, Keller, Sacks, Yeh, & Lavori, 1992).
As well as considerable psychiatric morbidity,
mortality rates in eating disorders are raised com-
pared with the general population. Reported mortal-
ity rates from long-term follow up studies of AN and
BN are in the region of 0–5% (Sullivan, 1995; Keel,
Heatherton, Harnden, & Honig, 1997). In addition,
DSM-IV recognises a third category termed “eating
disorder not otherwise specified,” which includes dis-
orders of eating that do not meet criteria for AN or
BN. This category is important because this group of
conditions is more common than AN or BN and the
individuals who fall into this category still experience
major disturbance and domination of their lives by
extreme concerns about body shape and weight as
well as a significant disruption of their eating patterns.
“Binge eating disorder” appears in the appendix of
DSM-IV as a category of eating disorder requiring
further study. The main features of this disorder are
18:8 Style file version Nov. 07, 2000
binge eating without the inappropriate compensatory
behaviors of BN. The disorder commonly occurs with
obesity (Fairburn, Cowen, & Harrison, 1999).
The potential influence of maternal eating disor-
ders on child development will be considered broadly
chronologically as follows: beginning before concep-
tion with genetic influences, then considering preg-
nancy, the postpartum period, and infancy and early
childhood where we focus specifically on topics such
as feeding and growth and general parenting. We then
move onto later childhood, to parental concerns about
their children’s weight and shape, the possible de-
velopment of psychopathology in the children, and
adolescence.
GENETIC FACTORS
It has long been recognized that eating disorders
aggregate in families (Strober, Morrell, Burroughs,
Salkin, & Jacobs, 1985). Family studies report a
higher risk for eating disorders in first-degree relatives
than in relatives of controls (Strober, 1991; Strober,
Freeman, Lampert, Diamond, & Kaye, 2000; Strober
et al., 1985). Two of the largest and most systematic
of these studies (Lilenfeld et al., 1998; Strober et al.,
2000) found a 7–12-fold increase in the prevalence of
AN and BN in relatives of individuals with eating dis-
order compared with controls, providing strong sup-
port for familial transmission of both types of eating
disorder. Cross-transmission of AN and BN in fam-
ilies suggests a common or shared familial diathesis,
which extends to milder eating disorder phenotypes
(Strober et al., 2000).
Twin Studies
As first-degree relatives share both genes and
environment, family studies are unable to differen-
tiate genetic from environmental effects. To establish
this differentiation, twin studies have been conducted,
which compare similarity for a trait or disorder be-
tween dizygotic (DZ-nonidentical) and monozygotic
(MZ-identical) twins; MZ twins share around twice
as much genetic material as do DZ twins. Early re-
ports (Holland, Hall, Murray, Russell, & Crisp, 1984;
Holland, Sicotte, & Treasure, 1988) found that rates
of AN were much higher in MZ than in DZ twins (56
vs. 5%) and suggested that up to 80% of the variance
in liability to AN may be accounted for by genetic
factors. In contrast, analyses on a subset of twins with
BN found negligible genetic involvement (Treasure