Introduction

Meal preparation and consumption provide families with the opportunity to connect and communicate. During these times, parents play an important role in shaping their children’s weight-related behaviors and attitudes. When a parent has an eating disorder (ED), the rituals associated with food may create problems for themselves and their family, especially children. In a series of sixty-two interviews with 8–13-year-olds drawn from the community, Schur and colleagues found that 50% of children wanted to weigh less and 16% reported attempting weight loss. From this group of young people, 77% of children reported hearing about dieting from a family member, usually the mother, highlighting the potential influence of parents in shaping children’s attitudes towards food and body image.

Most research has focused on maternal EDs, primarily because women are at higher risk of EDs than men (Fairburn and Harrison, 2003) and, in many countries, tend to be the primary caregivers of children. Epidemiological studies have estimated that 4% of women of childbearing age have a form of ED (Fairburn and Harrison, 2003). The Diagnostic and Statistical Manual of Mental Disorders (5th edn., DSM-5) (American Psychiatric Association, 2013) classifies four distinctive EDs. Anorexia nervosa (AN) is characterized by an intense fear of gaining weight, distorted body image, and dietary restriction that leads to weight loss. Women affected by AN often have minimal body fat and muscle development. Conversely, women who present with bulimia nervosa (BN) exhibit frequent episodes of bingeing, in which they lose all sense of control, followed by inappropriate compensatory behavior, including excessive exercise, purging, laxatives, and food and fluid restriction. In appearance, women with BN look relatively healthy and often maintain a stable body weight. The third disorder is binge-eating disorder (BED), which is similar to BN though women presenting with BED do not engage in compensatory behavior and are often heavier. Not all individuals presenting with disordered eating fit within these classifications. Individuals presenting with some but not all diagnostic criteria for one of these disorders may be deemed as having the fourth and final disorder – namely, other specified feeding and eating disorder (OSFED).

The prevalence and impact of paternal ED on families as well as the family functioning of adolescents with EDs are important avenues for future research; however, both issues are outside the scope of the present chapter. This chapter will critically review the possible mechanisms by which having an ED may influence mothers’ parenting and feeding behavior and subsequent child well-being. Genetic factors involved in this transmission, perinatal difficulties, and mothers’ parenting behaviors during infancy, childhood, and adolescence will also be examined. Promising intervention programs along with other strategies that clinicians may employ to support mothers conclude this chapter.

Genetics

Genetic influences play a role in this area; for example, in a twin study of 2,163 women, AN was estimated to have a heritability of 58% (Wade et al., 2000), though the authors were unable to rule out the contribution of a shared environment. It can be difficult to disentangle genetic from environmental factors, as first-degree relatives share both genes and environment (Bansil and Kuklina, 2009).

Perinatal difficulties

One of the side effects of having a low body weight and irregular hormonal balance is the irregularity of menses. Women exhibiting AN often experience amenorrhoea and reduced fertility and may be sexually inactive (Brinch et al., 1988), while women with BN have greater rates of oligomenorrhoea (Morgan et al., 1999). Some unplanned pregnancies occur because women believe they are not able to conceive due to having irregular menses. As pregnancy inevitability involves weight gain, becoming a mother may be accompanied by an increased fear of gaining weight; fear of losing control over weight gain; and, for with those AN, fear of losing a potentially valued “anorexic identity” (Easter et al., 2011).

Fetal development is largely dependent on maternal nutrition, and mothers are encouraged to increase caloric intake throughout the final two trimesters and increase micronutrients such as iron, folate, and vitamin C (Food and Nutrition Board Institute of Medicine, 2002). The restrictive eating in AN and binge eating in BN and BED may compromise these needs. Siega-Riza and colleagues (2008) investigated the eating patterns of women with BN and BED during their first trimester and found that both groups were more likely to consume a higher energy total and lower micronutrient content than women with no eating disorders. Interestingly, women diagnosed with BN before pregnancy were more likely to classify as BED during pregnancy, a finding which may reflect a general avoidance of fattening food and increase in food consumption as intervals of purging decrease.

Micali and colleagues (2012) investigated the dietary patterns of women with AN, BN, and both AN and BN as well as those of women without ED in their third trimester of gestation. Results showed that women experiencing ED were more likely to adopt a health-conscious, vegetarian diet, opting for fewer meat and potato dishes and increased soya products in comparison to women who were not experiencing ED. In addition, women experiencing ED consumed >2,500 mg of caffeine per week, significantly greater than the recommended amount of 200 mg per day, a pattern of behavior that may be adopted as a mechanism to suppress appetite and stimulate cellular activity (Micali et al., 2007). This means that women with BN may be at increased risk of miscarriage throughout pregnancy. Among women who carry their unborn child to full term, there is a greater tendency to give birth prematurely (Sollid et al., 2004) or, for those with AN, to bear a significantly underweight child (Micali et al., 2007).

Parenting behaviors throughout infancy, childhood, and adolescence

Women experience major role and relationship changes when becoming a mother. This experience may be curative, or it may make their ED worse. As summarized by Park and colleagues (2003), disruptions to routines may make it difficult to establish eating patterns, and, for some mothers, the pressures of constantly attending to an infant’s feeds may trigger binges. Conversely, having a baby may promote recovery and provide a reason for remaining healthy (Park et al., 2003).

During infancy, feeding and mealtimes may also be difficult for mothers with an ED. While breastfeeding is nutritionally beneficial to the infant and can promote parent–child attachment, mothers preoccupied with their body shape may be reluctant to breastfeed (Park et al., 2003). While feeding is an important process where parents and infants communicate and infants learn self-gratification and autonomy (Stein and Woolley, 1996), having an ED may affect a mother’s ability to prepare meals, feed her infant, and respond to the infant’s hunger cues.

Furthermore, mothers with ED have been found to be more intrusive, experience greater mealtime conflict, and express more critical and derogatory remarks than other mothers (Stein and Woolley, 1996). This pattern of behavior may make these mothers reluctant to allow their child to self-feed due to their fear of mess and lack of food control (Stein and Woolley, 1996). Conversely, Park and colleagues (2003) found that mothers with BN give food to their infants for non-nutritive purposes (i.e., as a reward, to calm, or as a means of expressing love).

A mother’s regimented behavior around mealtimes may be mediated by anxiety and depression, precipitated by her concerns about body image, food consumption, and weight control (Micali et al., 2011). This preoccupation may interfere with a mother’s responsiveness and attunement to the child’s basic and psychological needs (Stein and Woolley, 1996).

This preoccupation was further explored by Stitt and Reupert (2014), who interviewed nine mothers with various EDs, one of whom reported that “food comes before everything.” While mothers indicated that being a parent was an important role, many prioritized their needs for routine (e.g., purging rituals) over the needs of their children. Another finding was the shame associated with having an ED and the need for mothers to keep their ED a secret from children. This was not always successful, however; one mother reported that her children did not know about her ED but simultaneously indicated that the children’s language for her purging was “sicky sick” (Stitt and Reupert, 2014, p. 513), suggesting that on some level her children knew that something was not right. Similarly, the mothers interviewed by Rørtveit and colleagues (2009) described feeling guilty and leading a double-life. Both studies indicated that mothers were concerned that their ED behaviors would adversely affect their relationship with their children and lead to the children developing their own ED.

During adolescence, most teens, especially girls, express concerns about body image and weight. Negotiating these topics can be particularly difficult for mothers with an ED who perceive their daughters’ body shape negatively, compared to other mothers, despite a lack of difference between their daughters’ weight (Agras et al., 1999). Some mothers talk negatively about their children’s weight, and this affects how their children perceive their own body (Stein and Woolley, 1996), while others believe that their inability to be honest about their own food consumption makes them incompetent in supervising their child’s food intake (Rørtveit et al., 2009).

Notwithstanding the impact an ED may have on parenting behavior, having children can be a motivator for recovery (Stitt and Reupert, 2014). A mother’s increased willpower, strength, and motivation for a better life for her child can assist in this process (Federici and Kaplan, 2008). However, motherhood may not be favorable to long-term recovery (Federici and Kaplan, 2008), as motivation may decrease when children move away from home (Stitt and Reupert, 2014). Thus, while parenthood may be an opportune time to intervene, the mother needs to be motivated to recover for herself as well as for her children.

Child outcomes

The children of mothers with an ED are at risk of various adverse outcomes related to their own eating, body concerns, and other mental health issues. There is evidence that problems in children may persist well after the remission of their mother’s ED (Park et al., 2003).

A mother’s pattern of feeding behavior during infancy assists with the regulation of self-gratification and autonomy (Stein and Woolley, 1996). Pervasive patterns adopted by mothers with an ED may increase a child’s risk of developing feeding complications and psychopathology. Decreased maternal responsiveness to child cues and increased controlling behavior have been connected to overeating and obesity in childhood (Anzman and Birch, 2009). Furthermore, lower maternal responsiveness is associated with underweight children who have been deprived of nutrition necessary for adequate development (Robertson et al., 2011). Stein and colleagues (1994) found that at 12 months of age, the infants of mothers with EDs weighed less than other infants. However, the most significant predictor of weight was the level of mealtime conflict between mother and infant, with more conflict being associated with the infant being lighter.

On the whole, however, the dietary patterns of children whose mothers have an ED are relatively healthy throughout early childhood. A longitudinal study investigated the dietary patterns of children of mothers with AN (n = 140), BN (n = 170), and AN+BN (n = 71) compared to children of women without EDs (n = 9,037). Children whose mother had either AN or BN had higher scores on the “health-conscious/vegetarian” dietary pattern than children whose mothers did not have an ED. Moreover, children of mothers with AN and BN had higher intake of energy and children of mothers with BN recorded higher intake of carbohydrates and starch and lower intake of fat than children whose mothers did not have an ED (Easter et al., 2013). As the children grew older (reaching 7 and 9 years of age), their diet reflected more of a “traditional diet” (meat and three vegetables). This shift in food groups may be reflective of the societal effects of school and children’s curiosity about what their peers are consuming.

Another longitudinal study found that children at the age of 10 were more likely to be dieting and hold overvalued ideas about body shape and weight, compared to other children (Stein et al., 2006a). As they mature, children begin to express concerns about restraint, weight, and poor body image (Stein et al., 2006a). By adolescence, children become increasingly aware of societal pressures of body image and may start to develop insecurities about body shape. This may create vulnerabilities towards modeling their mothers’ dysfunctional eating behaviors (Stein and Woolley, 1996).

Some studies have investigated children’s psychopathology, besides their eating patterns or body-image concerns. A Norwegian study found that mothers with BN and BED report higher anxiety symptoms in their 3-year-old children compared to children whose mother did not have an ED (Reba-Harrelson et al., 2010). Similarly, Micali and colleagues (2014) found that maternal ED was associated with different childhood psychopathology outcomes in boys and girls at 3½ years of age compared to children whose mothers did not have an ED. Girls of mothers with AN were more likely to have emotional, conduct, and hyperactivity disorders, and boys of mothers with AN were more likely to show hyperactivity. Girls of women with BN were more likely to show hyperactivity, and boys were more likely to demonstrate emotional and conduct disorders. However, it needs to be noted that the direct effect of maternal ED on children was small; instead, pregnancy anxiety and depression mediated the effect of maternal ED on children’s outcomes. A follow-up study on the same children at 7, 10, and 13 years of age found that children of mothers with ED had a twofold increased odds of having an emotional disorder, especially anxiety disorders (Micali et al., 2014). A limitation of these studies is that information on children’s outcomes was obtained from parents rather than from clinical measures. It also needs to be stressed that a significant proportion of children are unaffected by their mothers’ ED (especially those drawn from community settings), so it should not be assumed that all children will be adversely affected by their mothers’ ED (Park et al., 2003).