Misguided attempts at prevention for parents

One of the semi-implicit goals of ED Awareness Week is preventing eating disorders. Some of this information is geared towards sufferers themselves, with tell-all stories of how awful eating disorders are so people will know better than to go down that road (I don’t think this works, sorry). Other information is geared towards parents.

Sometimes, this is a good thing. I don’t think my parents knew I was high risk for developing an ED because of my perfectionism, anxiety, and drivenness. Nor did they know to trust their instincts when I started restricting and was blissfully ignorant that anything more sinister might be going on. They didn’t know that an ED can distort a person’s ability to recognize that something is wrong. This type of information is really good and I would LOVE to see more of it.

Too bad that’s not what’s appearing this ED Awareness Misinformation Week. Instead, we are treated to gems like:

Eating Disorders Often Begin At Home: On The Eve Of The Eating Disorders Week (The Almagest)

Food for Thought – National Eating Disorders Week
(Hamlet Hub)

National Eating Disorders Week: How Parental Behavior May Impact A Child’s Body Image (Forbes)

On the surface, these articles don’t look all that bad. In fact, they sound awfully positive. Here’s a way to help parents help their kids! How could it possibly send the wrong message? Here’s how:

It subtly (or not-so-subtly) blames parents for their kid’s eating disorder. In the Forbes article, the author notes that

Parents lead by example. Unfortunately, parents can also forget how their actions, thoughts and words can impact the lives of their children. When it involves body image and eating behavior, this can be especially relevant. Krasner feels that parents need to be mindful of how they eat, their relationship with their own bodies, and the potential impact on their kids.

Which, well, yes. Of course parental actions can affect children. But it’s a big leap to take this to actually creating an eating disorder. The problem is that parents can’t give their children an eating disorder. It doesn’t work that way. Although the message seems to be positive, it has a subtle message of blame. If a kid has an eating disorder, their parents were vain and obsessed with food and weight. Sure, sometimes that’s true, but that doesn’t mean that this talk caused the ED or that if you have an ED, it means your parents permanently screwed you up.

It gives parents a false sense of security. People think that because their kid knows about nutrition, doesn’t obsess about his/her thighs, or watched that Oprah show on how bad EDs were, that they won’t develop an ED. Theoretically, they know better.

But you can’t immunize your kid against an eating disorder so matter how much you love your butt. You can do everything right and your kid can still get sick.

It assumes body image problems are the driving cause of EDs. This isn’t even just a no. It’s a HELL NO. Yes, body image distortions were a factor in my ED, no doubt about it. But that wasn’t what was driving my behaviors. Research studies have shown that ED behaviors are driven by difficulties coping with and regulating emotions, NOT wanting to be thin. In fact, negative emotions make you feel shitty about your body. So is body image the cause of the ED or simply a symptom of the underlying depression and anxiety?

It conflates dieting with eating disorders. Another thing that pisses me off, also from the Forbes article (yep, they really got this one wrong!):

Based on more recent data, eating disorders are not only becoming more prevalent, but are also being noted in younger children. According to the National Eating Disorders Association, nearly 80% of 10-year-olds are afraid of being overweight.

While many factors contribute to the appearance and  development of eating disorders, a mother’s attitude regarding body image significantly influences how children view themselves.  One analysis found that a mom’s concerns about weight are actually the third leading cause of body image problems in adolescents and girls who believed their mothers wanted them to be thin and were two to three times more likely to worry about their weight. However, body image concerns aren’t just found in girls:  a study from the Harvard School of Public Health in 2013 noted that close to 18% of teen boys in their study were “extremely concerned” about their bodies.

In fact, casually discussing diet plans or describing a desire to lose weight when you are with teens or children can negatively influence your child’s body image.

And this has precisely what to do with eating disorders?

It’s stuck in a century-old understanding of EDs. Take this little gem from the Forbes article:

The early speculation, based more on early psychoanalytic models, had to do with the concept of food as nourishment.

“Some of this psychosocial understanding is related to behavioral concepts such as the role of attachment– rooted in “mother’s milk”, Krasner explained.  “This  primordial understanding is the role food plays in a relational understanding of eating disorders in the family”.

As Krasner describes, early hypotheses of the pathogenesis of eating disorders related to difficulties between parents as it pertained to “mothers milk”:  giving love, receiving love, sharing in food, sharing in food-related celebrations.”

I just…what? Has either the author or the so-called expert read any of the literature on eating disorders in the past decade? This is backwards, pig-headed outdated CRAP.

Perhaps Laura Collins says it best:

In fact, parents do not cause nor is there evidence we can prevent eating disorders. While the vapid bullet points about what parents should do are all quite true, they are true just because they are good parenting, not because they have anything to do with eating disorders.

An eating disorder diagnosis tells us nothing about how the patient was raised. Period.

The phrase “Parents lead by example” should never, ever, ever be used or implied when talking about eating disorders. This has to stop.

Imagine if you will that an article about cancer awareness gave a list of basic hygiene tips for parents, implying that cancer was a sign of lax hand washing. Imagine that early signs of cancer were treated as lightly as that you should “seriously consider” seeing a doctor?

Eating disorders are not a problem with “body image.” They are not treated, or prevented, with normal parenting. If you suspect an eating disorder ACT NOW.

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38 Responses to “Misguided attempts at prevention for parents”

  1. Do you think there are no steps parents can take to reduce the chances of their children developing an eating disorder? My 10-month-old daughter is likely genetically predisposed to an eating disorder (I struggled with anorexia and other disordered eating for almost two decades), so I am particularly interested in this topic. My only hope is trying to raise her to view dieting as a silly exercise at best and a dangerous activity at worst (I realize dieting doesn’t cause eating disorders …but it often is the final impetus).

    • Elizabeth- I am not a therapist, but I am a mother of 2 children highly genetically predisposed towards disorders. I have one with OCD and one with Aspergers. Here’s what you can do:
      1) Make sure they eat! Keep an eye on things. EDs get out of hand b/c malnourishment exacerbates disordered thinking and behaviors. You can be watchful and careful.
      2) Protect them proactively from triggers. This means discussing with them, as you mentioned, the futility rather than validity of dieting, if it should come up. Keeping them away from activities like exercise or food logs, even if that means needing to discuss not doing certain assignments for certain PE or health classes.
      3) Get them help immediately if you notice troubling behaviors. Excessive tics, obsessive thoughts or behaviors, anxiety- seek help BEFORE it blossoms into a huge debilitating problem.

    • There isn’t anything we know of that can systematically prevent EDs, no.

      Being aware is the best tool available. You know the signs of an ED all too well. Keep your eyes open for similar things in any of your kids. I would warn against participation in distance running, elite gymnastics and ballet, etc, just to be safe, but that’s me and not supported by research.

      Early intervention is the BEST option right now for EDs. Raising your daughter to view dieting as silly is incredibly powerful and good–even if it doesn’t always prevent EDs.

      • I think encouraging dieting or negative body talk predispose a child to dieting and bad body image, which may then (in some cases), lead to an ED. But that doesn’t mean that not dieting, eating healthy, and not talking negatively about one’s body is necessarily preventative.

    • Belinda Caldwell February 25, 2014 at 9:22 pm

      Agree with everything that people have said re prevention and the fact that EDs are not caused by diet and weight talk by parents. My d never aspired to be thin until she was sick and then was scared of gaining weight.
      However I am interested in my own ‘theory’, not currently evidence based, that possibly addressing earlier my daughters anxiety disorder, perfectionistic tendencies, ability to regulate her own emotions, obsessive compulsive tendencies etc may have made a difference. She lost weight trekking in Nepal but she describes the sensation of being hungry as an overwhelming sense of calm in situation where she felt very out of control and out of her comfort zone.
      She is now well into recovery and we are doing a lot of work on her ability to manage her anxiety, calm herself down when stressed etc. She actually says now she is glad she got the ED because she now has a lot of skills in dealing with stuff she has always struggled with.
      My tuppence worth is to, worry less about body image etc, keep them well fed, but also maybe make sure they have learnt a rang of skills for managing anxiety and stress and challenge their notions of perfectionism.

      • I have a stepdaughter who lives with us less than half-time, 16, who has been struggling with an ED since she was 13, and am desperate to keep my own daughter, 10, from developing an ED. I have wondered about your theory, Belinda, since reading Carrie’s post. If we had helped my SD manage her emotional swings/anxiety, could that have helped prevent her ED? Can I give my daughter tools that will keep her from developing an ED? My daughter will tell me she is overwhelmed in anxiety-producing situations (for her, approaching a group of peers where she could be rejected, or forgetting an assignment at school), and so far I have worked on breathing techniques, visualizations, and positive self-talk. Unfortunately I realize I may have already caused harm by getting angry with her in the past – over forgotten items, for example. Like I said, though, I’m trying to do everything I can at this point…I wish there was more info out there about this type of effort.

  2. Another aspect to the parent education week would be the possible effects that parents own eating disordered behavior or addictions have on their children. I grew up with a mother who was very sick with her own anorexia (although she continues to be in denial till this day) as well as other mental health issues. From the very get go that was the example I had and than combine that with perfectionism and trauma and it is a perfect storm. Even now in my 30 thirties I cannot be around my mother due to her complete lack of support for my recovery and her insistence of restricting and particpating in ed behaviors right in front of me.

    I would get sooo fustrated with women in treatment who had children and I repeatedly tell them how negatively of an impact they can have on how their own children view food and possibly set them up to be predisposed to develop and ED later in life. I am a living breathing example of that and my sister too suffers from anorexia largely due to the toxic enviornment that was our household.

    If I do nothing else in life – I will break the cycle that my mother established and I will set a good example of what healthy eating habits and attitudes toward food are.

    • Having a close relative with an ED makes you predisposed by the simple reason of genetics, regardless of whether the ED is active when the person is around. And parents deserve treatment for their ED even if it had no effect on their children.

      Unfortunately, you and your sister got hit by both the genetic and environmental risks of ED. But it’s impossible to say whether you would have gotten sick if you weren’t in that environment or whether someone who had less of a genetic risk would have developed an ED if they were raised in your household. I’m not naive enough to think that these things don’t matter, but we need to be cautious about talking about what we feel contributed to our own ED and what we know about what contributes to EDs on a broader scale. Everyone is entitled to his/her own story and to tell it without fear of criticism. That’s not what I’m trying to get at. While I absolutely stand behind your assertion that you feel your family contributed to your ED, I can’t quite get behind “families that are messed up about food cause EDs.” Does that make sense?

      I do hope you break that cycle and I wish you all the best.

  3. I consider myself lucky that the fact that I read, bought into and followed all the prevention advice didn’t prevent me from recognizing my daughter’s anorexia fairly quickly. I am very opposed to any article that talks about parents preventing eating disorders–it’s both a blame game and a smokescreen in my opinion.

  4. I am the youngest of 5 daughters in my family. I am one of four who WAS breastfed. I was breastfed the LONGEST at over a year. My mother struggled heavily with depression and became quite malnourished when my older three sisters were young- but by the time she had me, her body was full and HEALTHY and has remained so throughout my life.

    If parenting plays a part in ed development, then my oldest sisters had the highest chance of developing one, and I had the least. Yet, I am the only one out of the five who developed an ed! And I am also the only one on the autism spectrum.

  5. Sarah Stephenson February 25, 2014 at 4:47 pm

    Thanks, Carrie! It’s always seemed to me that the most likely way a parent can cause their child to develop an ed is by passing on certain genes, which may result in that child developing an ed, or an addiction, or some other physical symptom of a MENTAL HEALTH ILLNESS! Its no different to inheriting a gene which leads to breast cancer, diabetes or any other disease. Pointing the finger of blame at parents does not help those same parents to care for and support their beloved children into, through and beyond recovery.

  6. I think the tendency falls in the opposite direction: for parents to view their children’s eating disorders as something random (“it could happen to anyone”) or genetic, and thus absolve themselves entirely of their own role in causing, enabling, encouraging an eating disorder. I think the mistake in these articles is assuming that the family’s role is limited to comments about food and body size. But I do not know any ED patients who didn’t have pretty significantly dysfunctional families. There may be a few exceptions, but I do think that unhealthy family dynamics, while they may not cause an eating disorder where no predisposition exists, can mean the difference between a high-anxiety or body-dysmorphic kid, and a full-blown ED.
    My parents never said one word to me about my weight or eating, but my father was an emotional tyrant who pushed me relentlessly and tried to turn me into a boy, among other things. I suppose parents are supposed to know now to do that to begin with. Still, I feel like in treatment it’s easy for families to focus on their problem child and his/her problem ED, and deflect the attention from their own dysfunctionality. The problem I see with these articles isn’t that they shift the focus onto the parents, but that the focus is too narrow.

    • Dale, I am sorry you have faced this demon, but here’s another view. My parents co opted me to be a diet buddy, every Monday morning a new diet, tried them all. My father was also a bully and I was physically and emotionally abused. I nor my sister developed an eating disorder, we had body dysmorphia but no ED.
      I consciously watched my talk and body attitude around my daughter, she developed an ED. My son didn’t. If parents were the primary cause then I would assume my sister and I would be most at risk. My daughter at minimal risk. But my daughter had perfectionist tendencies, poor impulse control and a teacher who thought it was cool to discuss her diets with the children in year 6. My daughter also had the stress of nearly loosing her brother to illness and bullying at high school. She told me after recovery that she felt that if the perfectly wonderful healthy young woman around her were not satisfied with there bodies, what did that say about her. Peers and outside influences also play into this beast of an illness.
      My daughter credits us for hanging in there and insisting she ate each and every meal, with firm guidance and a no starvation zone she recovered and is now the happy healthy child she should be.
      We stayed together as a family and I learnt how strong our love was.
      Parents given the right support can and are heroic in facing down this illness, there others who struggle either due to circumstances or their own issues. Do not blame but understand their limits and put in evidence based support in the home.
      I hope you find your answers in life.

      • Thanks for responding with your story, Susan. I certainly wasn’t suggesting that there was any guaranteed causality: dysfunction family = child with ED. I am suggesting, based on the people with EDs I have known, that there is a high correlation in the other direction (child with ED = dysfunctional family), but I’m sure no model is 100% accurate and I know that stresses and causes can come from outside as well. In the end, I guess I am just saying that I would like the media to recognize that this is not a disorder that occurs in a vacuum, and that since children spend the most time with their families, it is quite likely that families contribute to eating disorders. (Also I think it would be useful to distinguish between recognizing correlation and blaming. No family is perfect, the important thing is to recognize what is causing the illness and work to change it). But certainly each family and ED is different, and generalizations should never take priority over the particular.

        • So if I read you correctly a child with Ed leads to dysfunctional family? I will almost guarantee you that if you as a stranger walk into a family where a child has Ed there will be stress, anger , blame, depression and possible despair and helplessness. Ed walks in when there is a high level of any of these events happening. But what comes first?
          We were a family coping with 19 years with a child with a life threatening illness, dysfunctional? When that illness threatened to take my sons life all anxieties and depression hit the heights on the Richter scale, dysfunctional? I was not sleeping and possible distant emotionally from my daughter, dysfunctional?
          We bandy that word around without any care, strangers can never ever presume to KNOW how families function but I KNOW that when a family faces a life threatens situation we may come across a little crazy, dysfunctional?
          With all due respect I have raised two children through life threatening situations, I have torn myself in two to cater for their differing needs , I have sat at hospital bedsides and the dinner table making sure everyone was nourished and sleeping well.
          I needed help with my depression and so did my husband, dysfunctional? No just normal everyday humans trying to keep their heads above water. We had no family support, but we survived I have one child in full time work, still with a life threatening disease, but working and contributing. My daughter training to be a speech pathologist and is looking forward to graduation so she can assist others to get well, dysfunctional?
          Well if that’s dysfunctional I will cop that I don’t care what label you toss in my direction I refuse to pick it up. But I will protect others who come after me, because I KNOW the full pain.
          It’s been a pleasure to talk with you and thank you for allowing me to reply.

          • Ah, my equals sign was ambiguous. I actually meant that the people with EDs I have known came from already dysfunctional families, not that the ED caused the family to become dysfunctional. But in any event, I stressed that I was speaking from my experience and that I know that no general statement can describe all ED situations. So I was not speaking about your family.

        • Actually, the best available scientific research evidence is that peers are a much stronger influence on teenagers than parents and families are. This has been confirmed in many scientific studies, including psychological studies of twins and other siblings, in which peer and family influences are controlled and altered over time and effects are measured.

          Furthermore, I don’t agree that the important thing is to “recognize what is causing the eating disorder and to work to change it.” First of all, it’s not possible to know what is causing the eating disorder. Second, it is not wise to let the eating disorder rule the family or other aspects of the environment, and expect the family and environment to cater to the eating disorder’s wishes. If something in the environment is causing the teenager to stop eating, the solution is not to change the environment, but to help her re-establish normal patterns of eating. Otherwise, the next time a similar environmental influence or stressor occurs later in life, the eating disorder will reappear, and you’ll have a pattern of relapse after relapse. The bottom line is that healthy people eat normally, regardless of the environment they happen to be in, and until you resume normal patterns of eating through all kinds of environmental changes, you aren’t recovered. Therefore, parents are not doing their kids a favor by changing the environment to appease the eating disorder.

          The most successful model of treating anorexia nervosa in teenagers, FBT, for example, does not try to do anything to change the environment in which the teenager lives. It does, however, endeavor to normalize the teenager’s eating behaviors, and to keep the eating behaviors normal over time, regardless of whatever is happening in the environment.

  7. Thank you. I am a mom who has been blamed by my own family for causing my daughter’s ED. This blame and guilt just convoluted the situation and made it harder to get help as I doubted myself for months on my ability to see things clearly and to help her.

    Again. Thank you. Thank you. Thank you.

  8. Does anyone have links to scientific studies on the role of family in the development of eating disorders?

  9. Thank you, Carrie. With all this old information out there & still in practice with some treatment providers, it is such a relief to read this powerful rebuttal. I think I am a much better support to my daughter when I am not wringing my hands over any guilt, but instead can listen to my gut & give her loving, firm encouragement to follow her treatment plan.

    • There are many scientific studies on the supposed role of the family in causing eating disorders. So far, not one has provided evidence that would lead a reasonable scientist to conclude that families are a signifant causal factor. A good place to start is Jacobi, Coming to Terms with Risk Factors for Eating Disorders: Application of Risk Terminology and Suggestions for a General Taxonomy, Psychological Bulletin 2004, Vol 130, No. 1, 19-65. This is a review of 320 scientific studies. The authors conclude that none of the 320 studies proves a causal role for families or parents. You can buy the full text of the Jacobi paper online, on the website for Psycholgical Bulletin. Subsequent to Jacobi, there have been a few more studies, each reaching the same conclusion, including Nicholls (above)and the twin genetic studies, including Klump, showing no detectable influence of “shared environment” i.e. family culture. The American Psychiatric Association has gone on record as stating “No evidence exists to prove that families cause eating disorders.” Practice Guideline for the Treatment of Patients with Eating Disorders, Third Edition, p. 26.
      Despite the absence of evidence, there are still many clinicians who adhere to the concept that parents and families are, or can be, significant causal factors. These clincians, however, have not offered evidence and tend to be those older clincians trained in “old school” ideas. We know from research that psychotherapists have a tendency to get “stuck” in patterns of thinking and experience great difficulty thinking flexibly and adapting to new evidence. A good study of this phenomonon is Cook, Apples Don’t Fall Far from the Tree: Influences on Psychotherapists’ Adoption and Sustained Use of New Therapies, http://www.ncbi.nlm.nih.gov/pmc/articles/PMC3675893/ The Cook survey found that most psychotherapists don’t adhere to evidence-based treatment methods. Kristen von Ranson, a researcher at a university in Canada, has studied the eating disorders profession. She has found a general lack of adherence to evidence-based approaches among ED professionals, as well as generally low levels of education and training. A further problem is that a majority (about 70%) of eating disorder clincians have a personal history of one or more mental disorders. (See 2013 paper by Courtney Warren on “job burnout” in the eating disorders profession.) Researchers are now exploring what role this widespread mental illness has on the tendency of eating disorder professionals to perpetuate myths about parents and families.

      • Thank you for sharing those references, Chris. I am fortunate to have access to an academic library and am able to read them. I would also recommend the article “The need for complex ideas in anorexia nervosa: Why biology, environment, and psyche all matter, why therapists make mistakes, and why clinical benchmarks are needed for managing weight correction” by Michael Strober and Craig Johnson, in International Journal of Eating Disorders, 2012, Vol.45(2), pp.155-178, which attempts to integrate the perspective of psychotherapists and research scientists.

  10. Carrie, I think you need to be really careful in making statements that completely write off research and stating that the information is ‘crap’.
    I don’t necessarily agree with all of the information provided online but it is incredibly ignorant and risky for someone in your position, writing this website, to assume that the experience you have had is that of every other ED sufferer. Conversation and learning around ED’s between those affected and health care professionals needs to be open and transparent and allow space for those affected by these disorders to voice their experience without feeling it wrong because it doesn’t fit into the neat box of ideas that are being sold at that point in time.
    Our peers, families, society, the media, our genetics, personalities and past traumas all interplay and unfortunately cause risk factors that if the person is unlucky, can cause ED. Families, parents and siblings naturally can play a part in our ideas and self concepts and it is naïve to state that the connection between parents and ED sufferers does not exist.

    • I have never said that there is no connection between parents and EDs. Anything that happens to us can, theoretically, alter out ED risk. My problem with articles like this is that they either ignore or distort the research out there. Right now, there is no good evidence to say that parents cause EDs or that if they do or don’t do something, it will keep their kid from getting sick. To suggest otherwise is wrong.

      I have no problem with people sharing their views or stories. Frankly, my view that parents don’t cause EDs isn’t exactly in the box. I object when opinion is presented as fact, so-called experts haven’t updated their knowledge in decades, and parents are told things that aren’t accurate.

      • Of course families, parents and siblings can play a part in our ideas and self concepts. However, there is no evidence that ideas or self concepts play a causal role in anorexia nervosa. The reality is that nobody knows what causes anorexia nervosa, nobody knows whether the causes are the same or vary from one person to another, nobody has developed a scientifically reliable method for determining cause, and nobody knows whether many things need to come together to cause AN or whether there is a single cause that hasn’t yet been discovered. As evidence that cause isn’t known, I would point to the fact that there is no proven method of prevention.

        Moreover, it is not reasonable to expect either a sufferer or a clinician to know the cause in a particular person; how could she? She can identify and explain events in her life that occurred before the onset of the eating disorder, but she has no way of knowing whether the events caused the anorexia nervosa, whether the eating disorder caused the events, whether the events and the anorexia nervosa are purely coincidental, or whether there is a third factor that caused both the event and the eating disorder. That said, reputable scientists have ruled out parents and families as a significant cause, using scientific techniques. For example, if parental and family influence were causal, you would expect brothers and sisters of sufferers to routinely develop anorexia nervosa at elevated rates, since they grow up in the same family as the sufferer. They don’t develop AN at rates higher than the general public, however, unless they happen to be identical twins with the sufferer and therefore have the same genes. (This is evidence that genes, not parents or families, play the main role in causation.) Furthermore, many studies have found no differences between families where anorexia nervosa develops in a son or daughter, and those where it doesn’t. (See, for example, the 30 year longitudinal study of 11,000 families by Nicholls and others in the U.K.) The evidence is now clear that the kinds of families in which a son or daughter develops AN run the gamut; there is no stereotype that applies. Some people with AN like their parents; some don’t. It appears to be irrelevant, however, to whether the person develops anorexia nervosa.

        Ultimately, looking for cause is futile, given the present state of knowledge. If the world’s leading experts don’t know the cause, how can we expect sufferers and their families to discover it? Even if the cause could be discovered, how long would it take? Are parents expected to sit around and let their kid starve while everyone is looking for the cause?

        Meanwhile, there is no evidence that even if we knew cause, it would lead to higher rates of recovery, since cause and treatment are separate issues. The leading treatment for AN in teenagers, FBT, is agostic as to cause. By contrast, the treatments that search for cause, such as psychoanalysis, are now know to result in very low rates of recovery. Consequently, its best to leave the question of causation alone, ignore it, focus on restoring everyone who sufferers from AN to health and helping them re-establish normal patterns of eating. Then re-engage with real life, leaving the eating disorder behind and moving on to other aspects of life that are really a lot more interesting and rewarding than an eating disorder.

    • Dale,
      That paper by Michael Strober and Craig Johnson is quite interesting. Unfortunately, it doesn’t offer any empirically validated methods for either prevention or treatment, or give any scientifically accurate information on causation.
      One of the authors, Michael Strober, is the head of the eating disorders program at UCLA. The website for the UCLA program includes a list of Suggested Readings. http://eatingdisorders.ucla.edu/body.cfm?id=28 At the top of the list is The Golden Cage, by Hilde Bruch (1978), a book that pretty much blames parents for causing anorexia nervosa. Sadly, Ms. Bruch suffered from severe mental illness. In 1935 she was admitted to a psychiatric hospital in a deep coma after a self-administered dose of barbiturates. She spent a considerable period of time in psychiatric treatment. She was described as confused, rebellious, prone to temper tantrums, and belligerant towards the treatment providers. This information came to light in a biography of Ms. Bruch written by her nephew’s wife, Joanne Hatch Bruch, entitled Unlocking the Golden Cage. Meanwhile, in the 35 years since The Golden Cage was published, the premise of the book has been debunked by scientific research studies. The fact that Mr. Strober continues to recommend The Golden Cage, however, should probably be taken into account when his ideas are evaluated, including the ideas expressed in that paper you cited. In other words, it’s probably a good idea to be as skeptical of Mr. Strober’s ideas as those of Ms. Bruch.

      Nobody really knows what causes anorexia nervosa or any other eating disorder. The best available evidence, however, from many studies across several scientific disciplines, has effectvely eliminated parents and families as significant causal factors.

      • Well, I was a patient of Dr. Strober’s at the UCLA NPI back in 1990 and I credit the program for saving my life. For what it’s worth.

        • I know several families that were treated by the UCLA Neuropsychiatric Institute. They say that it ruined their lives. For what it’s worth.

  11. i find this aspect of eating disorder research incredibly fascinating. i am the youngest of four girls and the daughter of a mother who had a serious eating disorder in her 20s. Out of my sisters, two of us struggled and two of us didn’t. The irony is no one sees it because of the co-dependent environment and the “we’re just really healthy, type-A, perfectionistic as a family.” I wouldn’t say they “caused” it, because it is hard to say if the conditions and variables had been different if I would have been different… but I will say they most certainly have impeded my recovery. I think genetics plays more of a role than people are willing to admit, and thus, I’m not sure we can cut out the parents role completely–similar to the fact that I am a dogged driven worker due to my parents influence and high expectations.

    • I have this debate with others about all aspects of our children’s behaviour. Nature or nuture? Were you a perfectionist due to environment or genes?
      As a parent I can tell you no two children come out the same, their personalities are there from the very beginning. Do we as parents really have all that strong an influence in fundemental traits?
      My daughter who developed an Ed is and was always a perfectionist with strong anxiety, my son, is such a polar opposite, he doesn’t give a damn about what anyone thinks and he will stubbornly do the exact opposite of what any authority figure requires of him.
      My daughter was neat , my son would never ever clean his room, I never fought with him over such silly things I thought the smell and mess would get to him…..it never did.
      Having said all this and many other things , I do think parents do and can have an influence on their child’s recovery. There are parents who enable the ED and there are others who cannot cope and others who fight with such strength and dignity.
      Parents may pass on genes, have all their own hang ups …hey they are human too. But they are in the best place to be there in the long run with love and stamina. I personally have learnt not to judge anyone so lets not judge our parents, let us acknowledge they are not perfect either, they have tried their best and made mistakes. Move on from blame and hurt and realise they gave you life and if you received a warm home and good education and some love you are in front.

      • I’m not sure people are “unwilling to admit” that genes play a large role. The best available research, mostly twin studies by Klump, Bulik, and others, are showing that genes explain about 50%-80% of the variance for anorexia nervosa. Almost all researchers agree, therefore, that genes are very important. The specific role of genes, however, remains unknown, and we shouldn’t assume those influencing personality are the ones that are relevant. It might be, instead, that the genes influencing eating-related hormones (leptin or ghrelin), genes influencing brain sensitivity to under-nutrition, genes influencing brain development during adolescence, or genes influencing other factors are the ones that matter. I don’t understand why anyone would think that genes influencing “Type-A” behavior or perfectionism are necessarily the ones that count. At this point, that would be speculation.

        Many sufferers tend to think that their tendency to be “doggedly driven workers” somehow caused or contributed to the development of anorexia nervosa. There actually isn’t evidence for this. In the Nicholls study (above) for example, researchers looked at 11,000 individuals and their families over 30 years from the date of birth in 1970 to 2000. As expected, about 100 (1%)of the individuals developed anorexia nervosa during that 30-year periord when they were young. The researcvhers then obtained the school records for all 11,000. They found that the 100 people who developed AN actually did not receive higher marks in school as children than those who did not. This indicates that the idea of people with AN necessarily being driven and compulsive high-achievers is a myth. Some people with AN are high-achieving in school, others aren’t, just as in the general population. Furthermore, there is no evidence that targeting high-achievement or dogged focus on work contributes to recovery from AN. Rather, targeting low weight and eating patterns is the key, based on the best available evidence. Many people can remain hard workers and high achievers and at the same time recover very well from AN; the two are not linked.

    • Actually, the overall record of the UCLA program isn’t anything to brag about. In 1997, Mr. Strober published a paper in the IJED reporting on outcomes in his program. He acknowledged modest rates of full recovery, and very protracted length of illness, with the average patient recovering in 57-79 months (5-7 years). See, Strober, The Long-term course of severe anorexia nervosa in adolescents: survival analysis of recovery, relapse, and outcome predictors over 10-15 years in a prospective study, Int J Eat Disord 1997 Dec; 22(4): 339-60. http://www.ncbi.nlm.nih.gov/pubmed/9356884

      These statistics do not compare favorably with FBT, which generally has shown higher rates of full recovery, in less than half the time, at a fraction of the cost of programs like UCLA’s. FBT is now recommended by the American Academy of Pediatrics. Programs like UCLA’s, which involve liberal use of inpatient psychiatric hosptialization, are not. The psychiatric hospital model has demonstrated low rates of success, worldwide, in the treatment of anorexia nervosa in teenagers, with severe psycholgical side-effects. (See, for example, Gowers TOUCAN and Godart.)

      In part, this poor record by UCLA might be explained by a disordered, irrational, and prejudiced stance toward parents and families. Insight into this aspect of the UCLA philosphy is afforded by a paper published in 1987, for example, in which Mr. Strober wrote that “the predisposition to eating disorders may well originate in genetically influenced variations in personality and temperament, but their ultimate expression requires the added presence of disturbances in family interactions and in other sociocultural pressures.” Strober, Familial Contributions to the Etiology and Course of Anorexia Nervosa and Bulimia, J of Consult and Clin Psychology, 1987, Vol. 55, No. 5, 654-59. The claim that the development of an eating disorder “requires” disturbances in family interactions is another way of saying that every single family is which an eating disorder develops was “disturbed” before the eating disorder developed and the “disturbance” played a role in causing the disorder. In reality, there is no evidence for this. It has been debunked by numerous studies showing that while some families in which an eating disorder develops might be “disturbed,” others are certainly not, just as in the general population. The fact that Mr. Strober would make such a bold assertion, however, without providing evidence for it, entitles us to question his judgment, open-mindedness, and skill. Meanwhile, the American Psychiatric Association has gone on record stating that “It is essential that the clincian avoid articulating theories that imply blame or permit family members to blame one another or themselves for the patient’s disorder…. Blaming family members harms their psychological well-being and often impairs their desire, willingness, and capacity to be helpful to patients and to participate actively and constructively in treatment and recovery.”
      APA Practice Guideline for the Treatment of Patients with Eating Disorders, Third Edition, p. 26.

  12. I hate to disagree or, rather, semi disagree, but my mother absolutely played an enormous role in causing my eating disorder. She did so more through hating her own weight and equating it to her own value in society than by any other means. When you are brought up with that thinking and an existing predisposition, there’s no chance of avoiding an ED. I absolutely believe that raising a child in an environment where the idea of body shame is taboo could help fight against the development of eating disorders.

    • I agree. I would never EVER say this is the case for everyone as it’s obviously not, but for me personally, I am quite sure of my mother’s causal role in the development of my ED. (Who is an amazing mother otherwise, but was very misguided in this area). And I think culture did play as role as well. I take full responsibility for my problems, but I cannot imagine my experience would have been the same if I’d grown up in a different household or in a culture that doesn’t value thinness. I do believe I was born with some definite “stuff” going on in my brain (tendencies toward anxiety and depression – which I’m sure also contributed to my ED severity) but the ED itself, no, I do think that was incredibly unnecessary FOR ME at least. I never had an issue with food or eating or my body until people told me I should have a problem with it (hence dieting > eating disorder)

      That being said, as someone who works in research, I totally believe that the evidence is not there as far as prevention recommendations, and that NEDA and other outlets could be doing a much better job reporting on the research that is actually out there. I also recognize that I cannot in actuality tell if my mother or anything else caused my ED, this is just my own (very emotionally driven) perspective. I hope that I can break the cycle for my own children and do better for them than was done for me, but I realize this won’t necessarily mean they won’t grow up with an ED.

      • Thank you, cq and anon-for articulating better than I seem to have been able to. You get it, and for that I’m grateful.

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  1. News You Can Use – February 23 – March 2 2014 « Eating Disorder Pro - February 25, 2014

    […] Misguided Attempts at Prevention for Parents – Parental actions can affect children. But it’s a big leap to take this to actually creating an eating disorder. The problem is that parents can’t give their children an eating disorder. It doesn’t work that way. Although the message seems to be positive, it has a subtle message of blame. Learn More. […]