Anorexia Nervosa and Parental Bonding: The Contribution

of ParentGrandparent Relationships to Eating Disorder

Psychopathology
m

Laura Canetti , Kyra Kanyas , and Bernard Lerer

Hadassah University Hospital, Israel
m

Yael Latzer
University of Haifa, Israel
m

Eytan Bachar
Hadassah University Hospital and the Hebrew University
of Jerusalem, Israel

The present study adopted an intergenerational approach in examining

the association between parental bonding and anorexia nervosa. Fortythree anorexic participants and 33 nonclinical comparison participants
completed eating disorder questionnaires and the Parental Bonding
Instrument (PBI). The participants parents also completed the PBI.
The anorexic participants perceived both parents as less caring and
fathers as more controlling than nonclinical participants. Among
anorexic participants, mother control and father care were associated
with symptom severity. Intergenerational effects were present.
Among anorexic participants, maternal grandmother care was associated with eating disorder psychopathology. The present findings
suggest that parental characteristics of grandparents might play a role
in the development of eating disorders in granddaughters. & 2008
Wiley Periodicals, Inc. J Clin Psychol 64: 703--716, 2008.
Keywords: anorexia nervosa; intergenerational; parenting effects;
parental bonding

*These two authors have contributed equally to this paper.

Correspondence concerning this article should be addressed to: Laura Canetti, Department of
Psychiatry, Hadassah University Hospital, P.O.B 12000, Jerusalem 91120, Israel; e-mail: lcanetti@hotmail.com

JOURNAL OF CLINICAL PSYCHOLOGY, Vol. 64(6), 703--716 (2008)

& 2008 Wiley Periodicals, Inc.
Published online in Wiley InterScience (www.interscience.wiley.com). DOI: 10.1002/jclp.20482

704

Journal of Clinical Psychology, June 2008

Anorexia nervosa is a serious psychiatric disorder characterized by an intense fear of

weight gain, signicant weight loss, and distorted body-self image. Its etiology is
supposed to be multidetermined by developmental, sociocultural, and biological
factors. Family studies demonstrated greater lifetime prevalence of eating disorders
among relatives of individuals with an eating disorder (Strober, Freeman, Laspert,
Diamond, & Kaye, 2000). Although there is evidence from twin studies that genetic
factors play an important role (Wade, Bulik, Neale, & Kendler, 2000), not all the
variance can be explained by biological processes and obviously some environmental
factors contribute to this family pattern. Among these factors, parentchild
relationships may be meaningful in the etiology of anorexia nervosa and may be
transmitted from generation to generation.
From a psychoanalytic viewpoint, abnormal motherdaughter relationships
underlie the later development of eating disorders: Bruch (1973) emphasizes the
mothers failure to provide adequate external responses to the childs inner state,
which leads to confusion between emotional experiences and biological needs. She
also suggests that the obedience and conformity characteristic of the anorexics
behavior is related to little or no encouragement of independence during the
individuation and separation phase (Bruch, 1982). Later formulations in the
framework of self psychology assume that anorexia nervosa, as well as other
disorders of the self, are the result of a chronic disturbance in the parents ability to
maintain an empathic attitude toward their child (Geist, 1989; Goodsit, 1985; Sands,
1991). Family therapists emphasize the role that disturbed family relationships play
in the etiology and course of eating disorders. Minuchin, Rosman, and Baker (1978)
identied an enmeshed, overprotective family structure, with individual boundaries,
often diffuse and weak. Sours (1980) saw the typical family of the anorexic as one
that supercially functions well, but enmeshes its members, is overprotective, rigid,
and lacks an ability for conict resolution.
Parker, Tupling, and Brown (1979), in an effort to describe normal parental
relationships from the standpoint of the parental contribution to the parentchild
bond, developed the Parental Bonding Instrument (PBI), which measures two
principal dimensions: one of care for the child and a dimension of psychological
control over the child. The combination of the two dimensions allows participants to
be classied in one of four types of parental bonding: optimal, weak, affectionate
constraint and affectionless control (Parker et al., 1979). Several studies on eating
disorders designed to test psychodynamic and family theories use the PBI. Works
that merged anorexia and other eating disorders indicated that individuals with
eating disorders rated both parents as less caring and more controlling than
nonclinical comparison participants (Calam, Waller, Slade, & Newton, 1990; De
Panlis, Rabbaglio, Rossi, Zita, & Maggini, 2003). Studies focusing on the anorexia
nervosa group yielded less consistent results: Mothers were reported to be less caring
compared to the nonclinical group (Bulik, Sullivan, Fear, & Pickering, 2000; Gomez,
1984; Palmer, Oppenheimer, & Marshall, 1988; Steiger, Van de Feen, Goldstein, &
Leichner, 1989). To a lesser extent, anorexia nervosa participants reported their
fathers to be less caring (Bulik et al., 2000; Steiger et al., 1989) or more controlling
(Steiger et al., 1989) relative to the nonclinical group.
In recent years, there has been an increasing interest in the intergenerational
transmission of parenting effects in elds such as harsh parenting, intimate violence,
sexual abuse, parental rejection and depression, and adolescent mothers (Brook,
Whiteman, & Brook, 1999; Brook, Whiteman, & Zheng, 2002; Chapple, 2003; Hess,
Papas, & Black, 2002; Leifer, Kilbane, Jacobsen, & Grossman, 2004; Simons,
Journal of Clinical Psychology

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Anorexia Nervosa and Parental Bonding

705

Whitbeck, Conger, & Chyi-In, 1991; Whitbeck et al., 1992). However, according to
our literature review to date, no intergenerational research has been conducted on
eating disorders.
The mechanisms responsible for intergenerational effects are still not clear. Some
authors had proposed the attachment theory as the conceptual framework for their
research, whereas others had proposed learning theories or a combination of both.
The attachment theory (Ainsworth, Blehar, Walters, & Wally, 1978; Bowlby, 1973,
1988) focuses on the infants use of the caregiver as a source of security. Research
shows that individuals with eating disorders are more likely to be insecurely attached
than individuals without eating pathology (Armstrong & Roth, 1989; Broberg,
Hjalmers, & Nevonen, 2001; Kenny & Hart, 1992; Orzolek-Kronner, 2002).
According to the attachment theory, working models of the self, others, and
selfother relationships are transmitted across generations and are responsible for
the continuity of parenting behaviors. In our understanding, the parents experiences
with their own parents lack of care or controlling attitude may lead to an internal
representation of such relationships, which, in turn, impact the parents attitude
toward their children. Learning theories (for example, Bandura, 1986, 1997)
postulate that parental inuence on next generations occurs through a process of
modeling and reinforcement. In this instance, a more direct modeling process takes
place as the lack of care or controlling attitude of grandparents is imitated by the
parents in their relationships with their own children.
Until today, most research has focused on the comparison of parentchild
relationships of eating disorders to those of a nonclinical group. A related question is
how parental bonding is associated with severity of symptoms within the eating
disorder group. The few studies that deal with the relationship between parental
bonding and eating disorder symptoms found signicant correlations between eating
pathology and parental bonding style (Haudek, Rorty, & Henker, 1999; Furnham
& Husain, 1999; Turner, Rose, & Cooper, 2005), but one study failed to replicate
previous ndings (Furnham & Adam-Saib, 2001). Clinical samples of eating disorders
have not been included, which might be the reason for the inconsistent results.
The purpose of the present study was threefold. The rst purpose aimed to
replicate and extend previous ndings comparing anorexia nervosa patients to a
nonclinical group and comparing their respective parents on the PBI. The second
purpose was to investigate the intergenerational transmission of parenting effects
with respect to eating disorders. Our assumption was that the parental bonding style
of grandparents is associated with eating disorders in their grandchildren. The third
purpose of the present study was to examine the correlation between parental
bonding and severity of symptoms among the anorexia nervosa diagnosed
participants. This part of the study was conducted under the assumption that the
parental style contributes not only to the existence of an eating disorder, but also to
the degree of its severity. According to the intergenerational framework, we also
inspected this relationship across generations.
To assess the severity of the disorder, two measures of eating psychopathology were
used: The Eating Attitudes Test (Garner & Garnkel, 1979; Garner, Olmsted, Bohr, &
Garnkel, 1982) is a self-report measure of the symptoms and concerns characteristic
of eating disorders and is oriented toward the behavioral parameters of the disorder,
and the Eating Disorder Inventory (Garner, 1991), also a self-report measure intended
to tap psychological dimensions that have been postulated to be more fundamentally
related to eating disorders. The inclusion of these instruments was aimed to deal with
both the behavioral and personality aspects of anorexia nervosa.
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Journal of Clinical Psychology, June 2008

The hypotheses were:

1. Anorexia nervosa participants will report their mothers and fathers to be less
caring and more controlling relative to the participants in the nonclinical group.
2. A greater proportion of anorexia nervosa participants will exhibit an affectionless
control parental bonding style compared to the nonclinical group.
3. Grandparents of anorexia nervosa participants will be perceived as less caring and
more controlling compared to grandparents in the nonclinical group.
4. Less parental care and more parental control will be associated with greater
eating disorder psychopathology in the anorexia nervosa group.
5. Less grandparental care and more grandparental control will be associated with
greater eating disorders psychopathology in the anorexia nervosa group.

Method
Participants
The participants of the study were 43 anorexic young women, whose mean age was
21.3 years (SD 5 3.7), their mean years of school was 12.5 (SD 5 1.8), their mean
body mass index (BMI) was 16.7 (SD 5 2.1) with a BMI range of 11.3 to 17.4. The 36
mothers had a mean age of 49.8 years (SD 5 6.1), and their mean years of school was
14.1 (SD 5 4.1). The 31 fathers had a mean age of 53.5 years (SD 5 7.3), and their
mean years of school was 14.9 (SD 5 2.7). All anorexic participants met the criteria
according to the Diagnostic and Statistical Manual of Mental Disorders, Fourth
Edition (DSM-IV; American Psychiatric Association, 1994) for anorexia nervosa.
Eighteen anorexic participants were of the restrictive type and 25 were binge eating/
purging type. Five of the anorexic participants were also diagnosed with comorbid
major depressive disorder. Thirty-three nonclinical young women participated, their
mean age was 22.3 years (SD 5 4.5), with mean years of school of 13.2 (SD 5 2.2), a
mean BMI of 21.2 (SD 5 2.3), and BMI range of 18.1 to 26.5; 37. The mothers had a
mean age of 50.8 years (SD 5 6.5), with mean years of school of 15.5 (SD 5 3.6). The
35 fathers had a mean age of 53.1 years (SD 5 7.2), with their mean years of school
of 14.8 (SD 5 3.1). Ten mothers in the anorexia nervosa group had a history of
eating disorders. The nonclinical families (parents and daughters) and the parents of
the anorexic daughters did not meet DSM-IV criteria for any current psychiatric
disorder. There were no signicant differences between the anorexic and nonclinical
groups in age and years of education of mothers, fathers, and daughters. There were
no differences between anorexic participants, restrictive type, and anorexic
participants, binge eating/purging type, for all the variables measured in the study
except for the bulimia subscale of the Eating Disorder Inventory. The mean bulimia
score of anorexics binge eating/purging type was greater (M 5 4.8, SD 5 5.4) than
the score of anorexics restrictive type (M 5 .78, SD 5 1.3), t (41) 5 3.5, p 5 .002. For
all the variables measured in the study, there were no differences between anorexic
participants whose mothers had a history of eating disorders and those who did not.
Instruments
The Eating Attitudes Test (EAT-26; Garner & Garnkel, 1979; Garner et al., 1982)
is a well-established instrument that measures symptoms and concerns characteristic
of eating disorders. It is a 26-item self-report factor analytically derived scale,
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707

originally validated on 160 women with eating disorders and 140 female nonclinical
comparison participants. It is reliable and valid, correlates highly with the original
40-items scale (r 5 0.98; Garner et al., 1982) and screens for cases of eating disorders
in both clinical and nonclinical participants. Each item is scored on a 6-point Likert
scale and summed for a total score, with answers ranging from never to always. The
three least frequent categories (never, rarely, and sometimes) are given a score of 0,
often is scored as 1, usually is scored as 2 and always is given a score of 3. In the
present study, the EAT-26 was found to have high internal consistency (a 5 .93).
The Eating Disorder Inventory-2 (EDI-2; Garner, 1991) is a 91-item, standardized
self-report measure consisting of 11 subscales that assess specic cognitive and
behavioral dimensions of eating disorders: drive for thinness, bulimia, body
dissatisfaction, ineffectiveness, perfectionism, interpersonal distrust, interoceptive
awareness, maturity fears, asceticism, impulse regulation, and social insecurity. The
last three subscales are new to the revised edition of the EDI-2. The original EDI-2
demonstrated good internal consistency as well as good convergent and discriminant
validity (Garner, Olmsted, & Polivy, 1983). Alpha coefcients for the eight original
subscales range from .82 to .90. Internal consistency for the three new subscales is
fair to good, with alpha coefcients between .70 to .80. The EDI-2 has been used in
numerous studies and has been found to successfully differentiate between
participants with and without eating disorders (Garner, 1991). In the present study,
the internal consistency of the EDI-2 total score was high (a 5 .98) and fair to good
for most of the subscales: drive for thinness (a 5 .82), bulimia (a 5 .85), body
dissatisfaction (a 5 .84), ineffectiveness (a 5 .83), perfectionism (a 5 .77), interpersonal distrust (a 5 .79), interoceptive awareness (a 5 .71), maturity fears (a 5 .87),
asceticism (a 5 .73), impulse regulation (a 5 .86), and social insecurity (a 5 .86).
The Parental Bonding Instrument (PBI; Parker et al., 1979) is a self-report
questionnaire including 25 items, each describing a parental attitude toward the
subject. There are 12 care items reecting the dimension of care/involvement
versus indifference/rejection, and 13 control items, which measure the dimension
of control/overprotection/intrusion versus encouragement of independence. Participants are asked to rate each parent on a 4-point Likert scale, in which 0 is very like,
1 is moderately like, 2 is moderately unlike, and 3 is very unlike the parent in question.
Two scores are obtained for each parent, a care score and a control score. Scores are
computed so that the higher the score, the higher the care or the control exercised by
the parent. The care scale and the control scale may be used separately or together as
a bonding instrument. Used together, they allow four types of parental bonding to
be examined: high care and low control, which might be conceptualized as optimal
bonding, low care and low control, conceptualized as absent or weak bonding, high
care and high control, conceptualized as affectionate constraint, and low care and
high control conceptualized as affectionless control (Parker et al., 1979). In the
original version of the instrument, there were ve statements constructed with
double negatives. Parker (1983) found that participants were confused by these
statements, so, we implemented a corrected version, omitting the double negatives as
proposed by Gamsa (1987). Parker et al. (1979) reported good test-retest and splithalf reliability of the instrument. There is also concurrent validity of the two scales of
the instrument with rater scores obtained at interview. The PBI has been shown to
discriminate between neurotic and nonclinical populations: Neurotic subjects tend to
produce high control and low care scores (Parker, 1983). In the present study, the
PBI was found to have high internal consistency for all four scales: care scale
(mother: a 5 .93; father: a 5 .88), control scale (mother: a 5 .90; father: a 5 .88).
Journal of Clinical Psychology

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Procedure
Anorexia nervosa participants were recruited by systematically reviewing all patients
newly admitted to either the psychiatric department at Hadassah Medical Center in
Jerusalem or at Rambam Medical Center in Haifa during a 4-year period. All
anorexic participants agreed to participate in the study, but in two instances their
parents did not agree; therefore, these families were not included in the study.
Patients were interviewed by a clinical psychologist using the Schizophrenia and
Affective Disorders Schedule-Eating Disorders (Spitzer & Endicott, 1989) and were
considered eligible for recruitment if they met the DSM-IV criteria for anorexia
nervosa. After admission they were treated as either inpatients or outpatients,
according to the severity of their illness. Families of nonclinical comparison
participants were contacted through the social network of the anorexic families to
obtain subjects with similar occupational and educational levels. Initially, 43
comparison families were recruited, 10 of these families were subsequently
disqualied due to evidence that the daughter exhibited either a subclinical eating
disorder or other signicant psychiatric disturbance.
Anorexic and nonclinical participants completed EAT-26 and EDI-2 questionnaires. They also completed the PBI, describing the perceived relationship with their
parents. Participants completed the questionnaires in the same order as follows:
EAT-26, EDI-2, and PBI. Both parents of anorexic and nonclinical participants
completed the PBI questionnaire referring to their own parents.
The study was approved by the Helsinki Committee of the Hadassah University
Hospital. All participants signed an informed consent.
Data Analysis
We used t tests for independent samples to compare anorexic to nonclinical
participants in parental and grandparental bonding (rst and third hypotheses). Chi
squares were calculated to measure the association between parental bonding style
and anorexia nervosa (second hypothesis). Pearson correlation coefcients were
calculated to measure associations between eating disorders psychopathology and
parental bonding or grandparental bonding (fourth and fth hypotheses). Two-tail
signicance levels were provided. All statistical calculations were performed using
SPSS 13.0 for Windows.
Results
Means of parental bonding, EAT-26 and EDI-2 for anorexia nervosa and
nonclinical participants are presented in Table 1.
As hypothesized, anorexia nervosa participants reported both their mothers and
fathers to be less caring than did the nonclinical participants and they reported their
fathers to be more controlling than nonclinical subjects did. The difference between
the groups in mother control did not reach statistical signicance and therefore this
hypothesis was not supported.
To examine parenting effects on eating disorders in the second generation, PBI
measures of grandparents of anorexia nervosa participants were compared to those
of nonclinical participants. The bonding between the mother of the anorexic
participant and her own mother in the care or control scale was indicated as
maternal grandmother care/control and the bonding between the father of the
anorexic participant and his own mother as paternal grandmother care/control.
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Anorexia Nervosa and Parental Bonding

Table 1
Means (and Standard Deviations) of Parental Bonding (PBI), EAT-26, and EDI-2 in the
Anorexic and Nonclinical Groups

PBI scales
Mother care
Mother control
Father care
Father control
Maternal grandmother care
Maternal grandmother control
Maternal grandfather care
Maternal grandfather control
Paternal grandmother care
Paternal grandmother control
Paternal grandfather care
Paternal grandfather control
EAT-26
EDI-2

Anorexia

Nonclinical

M (SD)

M (SD)

26.8
12.0
22.7
10.3
23.4
10.9
24.3
11.5
28.1
11.0
26.6
10.5
39.0
80.2

(8.3)
(7.9)
(9.3)
(6.5)
(8.8)
(8.8)
(8.5)
(8.7)
(6.2)
(6.6)
(7.5)
(8.4)
(19.1)
(38.2)

31.6
9.5
28.8
7.5
24.6
11.1
27.3
9.8
26.9
8.8
25.6
6.5
5.9
23.5

(4.8)
(6.4)
(6.9)
(5.3)
(8.9)
(6.1)
(7.8)
(5.9)
(6.9)
(5.9)
(6.8)
(4.8)
(3.9)
(12.8)

df

2.94
1.45
3.15
2.02
.55
.09
1.50
.99
.78
1.45
.57
2.29
9.76
7.98

74
74
74
74
71
71
68
68
64
64
60
60
72
64

o.01
ns
o.01
o.05
ns
ns
ns
ns
ns
ns
ns
o.05
o.001
o.001

Note. PBI 5 Parental Bonding Instrument; EAT-26 5 The Eating Attitudes Test-26; EDI-2 5 Eating
Disorder Inventory-2; ns 5 not signicant.

A similar nomenclature was used for grandfathers. Contrary to our assumptions, no

differences were found between the groups in most of the PBI scales, with the
exception of one case. Control scores of the paternal grandfather of the anorexic
participants were greater than those of the nonclinical participants. Because
signicant correlations were found between paternal grandfather control and father
control (r 5 .31, po.05) and between paternal grandfather control and father care
(r 5 .43, po.001), we performed an analysis of covariance to determine whether
the difference between the groups in paternal grandfather control persisted after
controlling for father care and father control. In this analysis, father care was the
only signicant covariate, F (1,48) 5 9.02, p 5 .004, and there was no signicant
difference between the anorexia and nonclinical groups in paternal grandfather
control, F (1,48) 5 91, ns.
The classication in four types of maternal and paternal bonding and the
respective w2 for the 4  2 tables are presented in Table 2. As hypothesized, a
substantial percentage of anorexic participants characterized the bonding between
themselves and their fathers as one of affectionless control in contrast to nonclinical
participants. On the contrary, less anorexia nervosa patients reported an affectionate
constraint bonding with their fathers than did the nonclinical group. The
comparison of the affectionate constraint versus affectionless control categories of
paternal bonding for the 2  2 table by the Fishers exact test (df 5 1), was signicant
(p 5 .003).
Although a substantial percentage of anorexic participants characterized the
bonding between themselves and their mothers as one of affectionless control in
contrast to nonclinical participants, these results did not reach statistical signicance.
As hypothesized, among anorexic participants, parental bonding was associated
with the degree of eating disorder psychopathology (see Table 3). Mother control
was positively correlated with the EAT-26 total score, the EDI-2 total score, and 7
out of 11 EDI-2 scales. Father care was negatively correlated with EDI-2 total score
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Table 2
Comparison of Four Types of Parental Bonding (PBI) Between Anorexic and Nonclinical
Participants
Optimal

Affectionate constraint

Weak

Affectionless control

N (%)

N (%)

N (%)

N (%)

w2

15 (34.9%)
5 (15.2%)

7.4

ns

19 (44.2%)
6 (18.2%)

10.7

o.05

PBI Mother
Anorexia
Nonclinical

12 (27.9%)
18 (54.5%)

8 (18.6%)
7 (21.2%)

8 (18.6%)
3 (9.1%)
PBI Father

Anorexia
Nonclinical

14 (32.6%)
14 (42.4%)

1 (2.3%)
7 (21.2%)

9 (20.9%)
6 (18.2%)

and two of the EDI-2 scales. Mother care was associated to a lesser extent to eating
disorder psychopathology. No associations were found between father control and
symptom severity.
Results partially supported the hypothesis that the quality of the parental bonding
between parents and grandparents of anorexia nervosa participants was associated
with the degree of the eating disorder psychopathology in the anorexic daughters (see
Table 4). Mothers of anorexia nervosa patients that perceived their own mothers as
less caring, had daughters that reported more symptoms in the EAT-26 and in two
scales of the EDI-2, which measure the following eating disorder symptoms: drive
for thinness and bulimia. Fathers of anorexic participants that perceived their own
mothers as less caring, had daughters that reported more symptoms in the EAT-26,
and the EDI-2 total scores. However, due to the small sample size, even though these
correlations were quite substantial (r 5 .40; po.07 and r 5 .45; po.07,
respectively), they did not reach statistical signicance.
Discussion
The purpose of this study was to examine the association between the nature of
parentchild relationships and eating disorders with an emphasis on intergenerational parenting effects. We must keep in mind that these relationships were assessed
by a self-report measure. Although Parker (1983) reports good validity of the PBI, it
is possible that the measure reects perceived, rather than actual, relationships.
However, as Parker points out, the perceived characteristics of parents are not less
important than the actual ones in the development of psychological disorders
(Parker, 1983).
The present study replicates previous studies which found that anorexia nervosa
young women report their mothers to be less caring when compared to a nonclinical
group. Anorexic participants in this study also rated their fathers as less caring and
more controlling than nonclinical participants did, a nding which was not
consistent across all studies. These results support the hypothesis that low care
would be associated with anorexia nervosa. The care dimension of the PBI, which
comprises affection, emotional warmth, empathy and closeness, is theoretically close
to the requirement that the parent should be attuned to the childs inner states
(Bruch, 1973) and maintain an empathic stance (Geist, 1989; Goodsit, 1985; Sands,
Journal of Clinical Psychology

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27
.35
.26
.11

.16
.50
.35
.14

N 5 34

N 5 41

.18
.33
.15
.01

N 5 39

dt

.21
.15
.26
.25

N 5 39

.06
.34
.10
.02

N 5 39

bd

.01
.36
.14
.06

N 5 39

.19
.47
.08
.05

N 5 39

.18
.42
.23
.25

N 5 39

id

.11
.07
.18

.37

N 5 39

ia

.04
.31
.02
.13

N 5 39

mf

.33
.14

.37
.46

N 5 34

.07
.34
.55
.31

N 5 34

ir

.05
.49
.44
.15

N 5 34

si

Journal of Clinical Psychology

DOI: 10.1002/jclp

.40

.23
.45
.32

.44

N 5 27

dt

.24

.46

N 5 27

.12
.01

N 5 27

bd

.06
.16

N 5 27

.03
.03

N 5 27

.06
.36

N 5 27

id

.16
.37

N 5 27

ia

.18
.14

N 5 27

mf

.19
.36

N 5 23

.14
.33

N 5 23

ir

.23
.35

N 5 23

si

Note. PBI 5 Parental Bonding Instrument; EAT-26 5 The Eating Attitudes Test-26; EDI-2 5 Eating Disorder Inventory-2; dt 5 drive for thinness; b 5 bulimia; bd 5 body
dissatisfaction; i 5 ineffectiveness; p 5 perfectionism; id 5 interpersonal distrust; ia 5 interoceptive awareness; mf 5 maturity fears; a 5 asceticism; ir 5 impulse regulation;
si 5 social insecurity.
po.05; po.01.

Maternal grandmother care

Paternal grandmother care

N 5 23

N 5 27

.41

EDI

EAT-26

Correlations Between the PBI Scales of the ParentGrandparent Relationship and Eating Disorder Psychopathology in the Anorexia Nervosa Group

Table 4

Note. PBI 5 Parental Bonding Instrument; EAT-26 5 The Eating Attitudes Test-26; EDI-2 5 Eating Disorder Inventory-2; dt 5 drive for thinness; b 5 bulimia; bd 5 body
dissatisfaction; i 5 ineffectiveness; p 5 perfectionism; id 5 interpersonal distrust; ia 5 interoceptive awareness; mf 5 maturity fears; a 5 asceticism; ir 5 impulse regulation;
si 5 social insecurity.
po.05; po.01.

Mother care
Mother control
Father care
Father control

EDI

EAT-26

Correlations Between the PBI Scales of the ParentDaughter Relationship and Eating Disorder Psychopathology in the Anorexia Nervosa Group

Table 3

Anorexia Nervosa and Parental Bonding

711

712

Journal of Clinical Psychology, June 2008

1991) during child development. Parents who fail to be responsive to their children
will probably be perceived as less caring by the young adult.
Even though there seemed to be some consensus among family therapists
suggesting a pattern of intrusiveness, excess of care, and overprotection in eating
disorder families (Minuchin et al., 1978; Sours, 1980), these predictions were not
clearly conrmed in previous research: Among the studies reviewed, only one study
found more father control in anorexia nervosa participants (Steiger et al., 1989) and
another found more mother control (Gomez, 1984). In the present research, father
control signicantly distinguished between the groups, but maternal control was not
signicant. Paternal control was a signicant factor when combined with the care
scale: Among anorexia nervosa participants, the affectionless control category was
the most frequent. This category, which reects less affection and empathy combined
with excessive control and prevention of independence, seems to be associated with
the development of anorexia nervosa.
The present study examined, for the rst time, the impact of the bonding between
parents and grandparents on the anorexic granddaughters. The results suggest that
parental characteristics of grandparents might play a role in the development and
maintenance of eating disorders in their granddaughters.
Paternal grandfathers of anorexic participants were perceived as more controlling
than the grandfathers of the nonclinical participants, implying the intergenerational
transmission of parenting effects. However, when father care scores were controlled
this effect disappeared, suggesting that the grandfathers controlling behavior has an
indirect effect on eating disorders. The controlling behavior of grandfathers was
associated with more controlling behavior and less caring in their sons when they
became parents, as reported by their daughters, thus supporting the predictions of
the attachment theory regarding parents behavior continuity. Still, it is the
fatherdaughter relationship that has a direct impact on eating disorders.
According to Bruchs prediction that the prevention of independent behavior may
be pathogenic of eating disorders (Bruch, 1982), mother control was clearly
associated with the severity of the illness within the anorexia nervosa group. This
suggests that even though anorexia nervosa patients, as a group, suffer from lesser
mother (and also father) care, within this group, the more the control the more the
symptoms. Father and mother care were also associated, although to a lesser extent,
with eating disorder severity. These results conrm our hypothesis that the quality of
parental bonding is associated not only with the development of the eating disorders,
but also with its severity.
As previously mentioned, mother control was not signicantly different between
the anorexia and nonclinical groups and the control dimension yielded less consistent
ndings across the studies. It is possible that the control dimension does not play an
independent role and it is only the intertwinement of it with the care dimension that
has an impact on psychopathology. In other words, lack of closeness, indifference,
and lack of empathy may be more detrimental factors than excessive contact,
overprotection, intrusion, and lack of autonomy, at least in the etiology of eating
disorders. The study of Bulik et al. (2000), which examined the most disturbed
population of chronic anorexics, seems to conrm this assumption: They found that
the chronically ill anorexic participants reported signicantly lower maternal and
paternal care than the recovered group and lower maternal care even from the
partially recovered group, but there were no differences in parental control. Within
the anorexic group, grandmother care (from both the paternal and the maternal side)
was associated with severity of symptoms of anorexia nervosa in granddaughters.
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These results underline the central role of the care dimension of parental bonding in
eating disorders, which probably has an impact on eating disorder psychopathology,
directly and indirectly, and is transmitted across generations.
In this study, the assessment of illness severity included measures of attitudes and
behaviors concerning eating, as well as psychological traits clinically relevant to
eating disorders. Two psychological dimensions were found to be more consistently
associated with parental bonding: asceticism, which is the tendency to self-discipline,
self-denial and the control of bodily urges, and social insecurity or the belief that
social relationships are insecure, disappointing, and unrewarding. Asceticism was
associated with mother care and mother control. Social insecurity was associated
with mother control and father care. It is possible that the quality of the
parentdaughter relationship has a greater impact on the mentioned traits compared
to other traits, but these results are preliminary and further research is needed to
reach more denitive conclusions.
Studies of the intergenerational transmission of parenting effects have been
conducted in different elds of research, but rarely in the eld of eating disorders.
Our study is an initial contribution to the research of parentgrandparent
relationships and their impact on the quality of bonding between parents and their
child diagnosed with eating disorders. Our ndings may encourage other researchers
to inspect this neglected issue and to examine other aspects of the parentgrandparent relationships and how they affect family ties and eating psychopathology.
The present ndings are relevant to clinicians treating individuals with eating
disorders. They underscore the potential benets of family therapy, which aims to
deal with emotional difculties between the patient and her parents. Moreover,
clinicians conducting individual psychotherapy should consider parental counseling
as an important complement to treatment. According to our results, it may be useful
to design prevention programs focused on the parent population instead or in
addition to the adolescent or preadolescent population. These programs should
discuss issues of control, overprotection, and independence, as well as issues of
closeness, affection, and empathy in the parentchild relationship. It might be
worthwhile to discuss childhood experiences with their parents and how they
manifest themselves, sometimes in unconscious ways, in attitudes and behaviors
towards their children. The results of the intergenerational transmission of parenting
effects and its impact on eating disorders leaves many questions open to debate. The
mechanisms by which these effects operate might be complex; parenting styles may
be continued by means of working models as the attachment theory postulates, or by
modeling as learning theories assume, or even both processes may be present.
Further research is needed to elucidate this point. Alongside developmental
processes, we must be mindful of research evidence about the possible role for
genetic factors in the transmission of some child-rearing characteristics across
generations (Kendler, 1996).
In addition, when considering parentchild relationships, it is difcult to establish
the direction of the parenting effects. Does the eating disorder bias the individuals
perception of her parents? Moreover, does the eating disorder change the parents
behavior so the parent becomes actually less caring, or does the real lack of care
contribute to the development of eating disorders as psychodynamic theories
propose? Similarly, the controlling behavior may be a distorted perception of the
parent from the point of view of a deant anorexic adolescent or it may be new
parental attitude as the result of the parents effort to cope with the adolescents selfharming illness. In this respect, the intergenerational analysis can make some
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Journal of Clinical Psychology, June 2008

contribution. Because grandmother care was scored by the mothers (or fathers) of
the anorexic participants and because the parents did not suffer from the condition,
it is reasonable to suppose that the report of these relationships will be less biased by
the illness of their children. A similar argument is pertinent for grandfathers
intergenerational effects. This is still far from resolving the issue of causality, but this
rationale suggests that it is the real parentgrandparent interaction that has an
impact on the eating disorder of the granddaughter.
Even if we are not sure that the parents perception of their own parents is not
inuenced by their daughters illness, we must remember Parkers comment that the
perceived parenting is not less important than the real parenting and thus the
reported perceived parenting still keeps the idea of an intergenerational transmission
of parenting styles.
The results of the present study should be interpreted in the context of its
limitations. The small sample prevented us from analyzing the direct and indirect
effects in the correlation found between grandmother care and granddaughter
psychopathology. Additional research with a larger sample of anorexic participants
is required to replicate and clarify the nature of this association. The present study
design compared eating disorders to a nonclinical group. However, parental bonding
differences between anorexic participants and nonclinical participants may be
nonspecic to eating disorders as other neurotic populations show the same pattern
of parent styles. It is possible that low care and high control parental behavior is a
risk factor of psychopathology in general, not unique to eating disorders. Future
research including other mental disordered groups is needed to clarify this topic.
Future research might investigate theoretical questions left unanswered by this work
by examining the specic mechanisms operating in the intergenerational transmission of parental bonding.
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