Maternal perspectives on the intergenerational transmission of eating disorders

Abstract

Background

Studies indicate that the children of mothers who have eating disorders are at an increased risk of developing eating disorders themselves. The aim of this qualitative study was to broaden and extend current understandings of the experiences of mothers with eating disorders. The present report focuses on maternal perspectives, experiences, and support needs in relation to the intergenerational transmission of eating disorders.

Method

Semi-structured online interviews were conducted with parents living in the UK, USA, and Australia. Participants were eighteen mothers with a self-reported lifetime diagnosis of one or more eating disorders, who had experienced symptoms since becoming a parent, and who had at least one child aged 2 years or older. Data were analysed using reflexive thematic analysis.

Results

Four major themes relating to the impacts of having an eating disorder on children and intergenerational transmission were identified. These were: impacts (maternal perspectives on the ways having an eating disorder impacted their children, and their reflections around having been impacted by their own parents); breaking the cycle (strategies employed by mothers in efforts to prevent their children developing eating disorders of their own); communicating about the eating disorder (maternal experiences around disclosing or not disclosing having an eating disorder to their children); and support needs (maternal and perceived familial support needs in relation to breaking cycles of intergenerational transmission).

Conclusions

For mothers with eating disorders, concerns about the potential impacts on their children and fears about intergenerational transmission are salient, and these may vary for children at different ages. The mothers who participated in our study described engaging in a number of conscious strategies in efforts to manage the risks of eating disorder development in their children, but implementing these strategies was not without challenges. Implications for preventative programs to reduce the intergenerational transmission of eating disorders are discussed.

Plain English Summary

Previous research indicates that the children of parents who have eating disorders may be at greater risk of developing eating disorders themselves. Eighteen mothers who had been diagnosed with an eating disorder at some point in their life, and had experienced symptoms since becoming a parent, were interviewed. Interview data were analysed and themes were identified to describe maternal perspectives on the impacts of having an eating disorder on children. The themes identified were ‘impacts’, ‘breaking the cycle’, ‘communicating about the eating disorder’, and ‘support needs’. The findings suggest that mothers with eating disorders are concerned about a range of potential impacts of having an eating disorder on their children. A particular concern is that they may ‘pass on’ their eating disorder, and these concerns may vary for children at different ages. Mothers with eating disorders described engaging in a number of food and body image-related strategies to try to protect their children from developing eating disorders, but this is not without challenges. The support needs identified by mothers in this regard could usefully be incorporated in preventative programs, with potential benefits for both children and parents in families affected by a parental eating disorder.

Background

Eating disorders are complex illnesses associated with substantial psychological and physical morbidity [1], and significant mortality [2]. Although they can be experienced by anyone, approximately 8.4% of women are affected by a lifetime eating disorder [3], and many adults accessing eating disorder treatment are parents [4].

Studies suggest that the offspring of mothers with eating disorders may be at an increased risk of a range of feeding, cognitive and psychological difficulties (see [5] for a review), and studies have identified that these children are at an increased risk of developing eating disorders themselves [6, 7]. The process by which mental health problems may be transmitted from parent to child is complex, and both biological mechanisms (e.g. shared genes; epigenetic processes) and environmental factors (e.g. shared family, social, and cultural factors; parenting behaviours; modelling) are likely to be involved [8]. There may also be an interplay between these pathways that influences intergenerational transmission via gene-environment correlations and interactions [8]. Relatedly, whilst genetic factors are understood to play an important role in the transmission of eating disorders from parent to child [9], a wide range of biological, psychological and sociocultural risk factors are also implicated in their development [1].

With regards to environmental mechanisms of the intergenerational transmission of eating disorders, Treasure et al. highlight the possible effects on children of maternal attitudes, emotions, and behaviours in eating disorder-relevant domains, which may impact children directly or indirectly [10]. For example, maternal eating disorders may impact offspring directly by influencing the way a mother feeds her child [10] and, in line with Social Learning Theory which suggests that we learn most of the behaviours that we engage in from observing others [11], parents may impact children’s eating disorder risk by inadvertently modelling disordered eating behaviours [10]. A parental eating disorder may also affect a child through more indirect mechanisms, by impairing the quality of the parent–child relationship and the mother’s ability to be sensitive to their child’s needs [10]. Associated personality traits such as perfectionism, and comorbid diagnoses such as anxiety may also impact parenting and family relationships, and thus contribute to the intergenerational transmission of eating disorders [10].

In other areas of the preventative mental health literature, parent-focused interventions designed to reduce the transmission of mental health difficulties such as anxiety have begun to demonstrate considerable promise [12, 13]. However, whilst a handful of programs for parents with very young children have been described in the literature around parental eating disorders [14,15,16,17], to date there have been no studies of preventative programs that have been designed for offspring at the age at which eating disorders typically begin to emerge [18]. To inform the development of preventative interventions for children of parents who have eating disorders, it is crucial that we consider a broad range of parental perspectives around intergenerational transmission.

Whilst very little in the way of qualitative research has been reported for this group in recent years, a small number of studies exploring the broad experiences of mothers who have eating disorders have been described in the literature. Taken together, these indicate that parenthood may present particular challenges for some mothers with eating disorders, and that whilst becoming and being a parent can motivate eating disorder recovery [19, 20], these mothers may also experience conflicts in relation to their identity [20], and feelings of inadequacy as a parent [21,22,23]. They may also experience difficulties in relation to food-related parenting activities [24, 25] and with regards to their children’s weight and shape [22, 24, 26]. In addition, concerns about the effects of having an eating disorder on children are salient, with studies reporting maternal worries about modelling negative attitudes and behaviours around food and eating, and fears around intergenerational transmission [4, 27] which can also be accompanied by self-blame and guilt [23].

To date, most studies in this area have focused on the experiences of pregnant women or mothers of very young children [4, 21, 22, 24, 25, 27,28,29] and to our knowledge, only three qualitative studies have explored the experiences of parents with eating disorders who have older children. In Norway, Rørtveit and colleagues described the experiences of eight mothers with broadly defined eating difficulties, who were accessing treatment and who were parents to children aged between three and 25 years [26]. Tuval-Mashiach et al. described a study conducted with thirteen mothers with anorexia nervosa, bulimia nervosa, or eating disorder not otherwise specified (EDNOS), who were accessing treatment in Israel and who had children aged between 7 months and 24 years [20]. Most recently in 2014, Stitt and Reupert explored the experiences of nine mothers in Australia with anorexia nervosa, bulimia nervosa, or EDNOS, who were recruited from the community and who had children aged between 5 months and 27 years [19]. These three studies converged in reporting that mothers were concerned about the impacts of having an eating disorder on children; that mothers were worried about modelling in ways which might lead their children to develop eating disorders of their own; and that they experienced conflicts about whether or not to disclose their eating disorder to their children [19, 20, 26]. Despite these concerns, little is known about the support needs of parents who have eating disorders with regards to the risks of intergenerational transmission.

The overall aim of the present study was to broaden and extend the existing knowledge base around parental eating disorders, by exploring parent’s perspectives around the impacts of an eating disorder on their children, and how these impacts might differ according to children’s age and gender. Our study was open to parents who had children of any age, and we additionally sought to understand the experiences of parents with a range of eating disorder diagnoses, including binge-eating disorder, which has received very little attention in the literature on parental eating disorders to date. In addition to asking parents about the impacts of having an eating disorder on children and their support needs with regards to these potential impacts, we also asked parents about their parenting experiences in both general and eating disorder-relevant parenting domains, and about their individual support needs around having an eating disorder in the context of parenthood. Our findings concerning the latter are reported elsewhere [30].

Method

Having previously conducted a systematic review of the parenting attitudes, behaviours, and the parent–child relationship associated with parental eating disorders [31], the research team comprised LC (a PhD student with lived experience of eating disorders), and two clinical and developmental psychology researchers (SC and KL). SC is also a clinical psychologist. The extant literature and the findings of the aforementioned review informed the interview schedule for the study (Additional file 1), but all questions were open-ended and phrased in a non-directive manner. Participants were asked about their experiences of being a parent in both general parenting domains and those related to food, eating, and the body; the perceived impacts of having an eating disorder on their children and family relationships, and any differences for children at different ages (and according to gender where applicable); their parenting and coping strategies for managing their eating disorder in the context of being a parent; and their individual support needs as well as those perceived for their families. As data was collected during a period in which restrictions relating to the COVID-19 pandemic were in place, parents were also asked about whether the pandemic had impacted their parenting in general and eating disorder-relevant domains, as follow-up questions. LC conducted online semi-structured interviews with parents who had a self-reported current or prior eating disorder diagnosis, and analysed data using an inductive approach to reflexive thematic analysis [32]. The study is reported according to the Journal Article Reporting Standards for qualitative research (JARS; [33]). An author reflexivity statement is provided in Additional file 2.

Recruitment

To be eligible to take part in the study, participants were required to:

• Be aged 18 years or older

• Be the parent to at least one child aged 2 years or older

• Have received a lifetime eating disorder diagnosis

• Have experienced eating disorder symptoms since becoming a parent.

Participants were recruited online through advertisements posted on social media, including parenting groups, community groups, and support groups for people with eating disorders, and advertising materials and participant information highlighted that interviews would be conducted by a researcher with lived experience of eating disorders. Interested participants completed an online eligibility survey which also collected self-reported diagnoses, and eligible parents were invited via email to participate.

Before participating in an interview, parents completed an online consent form and demographic questionnaire, which included questions about non-eating disorder psychiatric diagnoses and whether symptoms relating to these diagnoses had been experienced since becoming a parent. Interviewees received an email thanking them for their time following their participation, which included signposting to support services.

Safeguarding procedures were in place in the event of any concerns arising during the course of an interview, and participants were informed of this before each interview commenced. At the start of each interview, participants verbally consented in addition to the consent provided online. The study received ethical approval (Review Number: ER/LAC25/8) from the University of Sussex Sciences & Technology Cross-Schools Research Ethics Committee.

Participants

Eighteen mothers aged 30–48 years (M = 38.5, SD = 3.94), who all identified as female took part in an interview. Twelve participants were based in the UK, whilst five participated from the USA and the remaining participant joined from Australia. There were 36 children across the full sample of mothers. 19 children were male (52.78%), while the remaining 17 (47.22%) were female. Children were aged 2–17 years, with a mean age of 9.67 (SD = 3.92).

Most mothers had been diagnosed with an eating disorder before they became a parent (n = 12). Fourteen mothers (77.78%) reported other psychiatric diagnoses, of which 10 (71.43%) had experienced symptoms of at least one of these since becoming a parent. Five mothers (27.78%) were currently accessing eating disorder treatment.

Additional demographic information is provided in Table 1, and self-reported eating disorder and other mental health diagnoses are presented in Table 2.

Table 1 Participant demographics

Table 2 Eating disorder and other mental health diagnoses

Data collection and analysis

Data was collected between April and November 2021 via Zoom. Interviews ranged in length from 35 to 97 min (M = 51) and were audio-recorded and transcribed verbatim. Following discussion between all members of the research team, data collection was completed after 18 interviews. Taking into account debate in relation to the concept of data saturation and its relevance in the context of reflexive thematic analysis [34], the information power model described by Malterud et al. [35] informed our decision to cease data collection. Having balanced the study’s relatively broad aim and cross-case approach to analysis against its dense sample specificity, and theoretical knowledge around eating disorders and the intergenerational transmission of mental health problems informing but not constraining analysis, it was considered that following 18 interviews the sample held sufficient information power. In addition, it was considered that at this point the participants that had been recruited represented a sufficiently broad range of eating disorder diagnoses, including participants with binge eating disorder.

Data was analysed using reflexive thematic analysis [32], adopting an inductive, critical realist approach. Each interview transcript was coded for any content relevant to the topic of having an eating disorder in the context of parenthood by LC using NVivo software [36]. Codes were initially generated through immersion in the data, and were extensive. Two rounds of coding were carried out before codes were grouped into tentative themes and subthemes. The thematic structure was developed through an iterative process, in which the corresponding data was under constant review, and the analysis regularly discussed by LC, SC and KL. The number of participants represented by each theme and subtheme was considered.

On completion of the analysis, it was identified that some themes were closely related to issues surrounding intergenerational transmission, while others were more closely aligned with general parental experiences of having an eating disorder (e.g. barriers to accessing treatment as a parent; children inspiring recovery). We decided to present these distinct areas in separate reports; only the themes relating to impacts on children and intergenerational transmission are reported here.

Results

Four themes relating to the intergenerational transmission of eating disorders were identified and are illustrated in a thematic map (Fig. 1). Quotes are abbreviated¹ and participant names are pseudonyms created via a random name generator.

Fig. 1

Thematic map

Theme 1: Impacts

Theme 1 captures the perceived and potential impacts of having an eating disorder on children as described by the mothers who participated in the study, and their reflections on having been impacted by their parents in eating disorder-relevant domains. The perceived and potential impacts of having an eating disorder on their own children included both indirect impacts (i.e. those related to the mother being unwell in a general sense) as well as those more directly related to eating disorder symptomatology (i.e. those related to the mother having an eating disorder, specifically). Mothers felt that having an eating disorder impacted - or could potentially impact - their children in a broad range of ways. Some perceived impacts were very tangible and specific. For example, mothers recalled occasions where children had missed out on social activities involving food because they had been unable to take them, or described impacts resulting from their being away from the family for prolonged periods for treatment. Some mothers with more than one child felt that the impacts were not equal for different children within the family. This was often due to age, where younger children were perceived to be less aware of the eating disorder and therefore less affected. Sometimes, this was because children were born at different stages of the mother’s illness, with those who had witnessed periods of acute illness being perceived to be more affected than those who had not.

“I just wouldn't go to things, so they would miss out on stuff 'cause, I just couldn't cope with... going out for a big meal with our friends or family, which is really sad.” (Rachel)

“… but my older child… I think… towards the end of my admission he started to struggle a little bit with the fact that I wasn't here and was getting a bit sort of distressed I think, or a bit worried, maybe.” (Juliet)

A primary concern described by mothers was that they might ‘pass on’ their body image and eating difficulties, and that their children might go on to develop eating disorders of their own. A few of the mothers of daughters highlighted their children’s gender, in the context of an increased risk of the development of eating disorders, as an additional cause for concern.

“I think I always, from the time it started, always feared having a daughter and I was always worried that she would look like me… I was so worried that I would have a daughter that would look like me and feel the way about herself that I do.” (Rose)

“… I was worried about transmitting my issues with food, I was worried about transmitting my… body issues. But also, it does get more subtle than that because, you know, I do have a real sort of problem with perfectionism.” (Esther)

“… Sometimes I worry that the kids might start to notice and mirror some of my behaviours…” (Juliet)

1a. Not wanting history to repeat itself

Relatedly, many mothers reflected on their own childhoods and the messages they recall being communicated by their parents in relation to food, eating and the body. Commonly, this included growing up around language where foods were categorised as either ‘good’ or ‘bad’; rules around consuming certain types of foods; or explicit expectations to not waste food.

“’cause… my parents, my mum mainly, was like "it needs using up, we waste it, think of all those starving children…" and that's always stayed with me. Or, you know, if it needs using up, the thought of wasting it, my mum's there in my head "think of all those starving children…", so I feel I’ve gotta eat it, get rid of it. And then it's just like, then I feel awful so then the exercising starts.” (Lina)

Some mothers also spoke of the ways they felt their own mothers had influenced their body image, or of the dieting behaviours they observed their parents engage in while they were growing up.

“… I remember, you know, my mum constantly being on a diet, when I was a kid. And she was only ever like a size 12² or a size 14… but because of that I had this perception that a size 12 or a size 14 was fat, and something that you had to change because I always saw her trying to change it.” (Esther)

A small number of mothers spoke of a sense of witnessing patterns from their own childhood repeating themselves with their children, sometimes through the direct messages communicated to them by their grandparents, which mothers described actively trying to manage and counteract.

“I notice like my mum or my mother in-law say “Ooh no, oh I’ve eaten... so I don’t think I’ll have any dinner tonight”… and I’m like “No, don't say that! Don't say that!” Or, “Ooh ooh you’ve eaten so mu-, oh, I can't believe how much you girls [PARTICIPANT’S CHILDREN] ate today. Gosh. I don't know where you put it!” and I’m just like “Don’t say that, like, I don't say that” (Rachel)

“I’ve tried so hard to not do… what my mum did to me, with telling me that the weight would fall off and letting me eat whatever I wanted.” (Nadia)

Theme 2: Breaking the cycle

Theme 2 refers to the conscious food- and body image-related strategies mothers described employing in their day-to-day parenting in attempts to reduce the risk of their children developing eating disorders themselves, and their efforts to ‘keep an eye out’ for early warning signs. Mothers also spoke of the challenges that they experienced, both arising internally and as a result of parenting within a wider ‘diet culture’, as they sought to protect their children from eating disorders.

2a. Do as I say, not as I do

Mothers described making conscious efforts around the way they communicated about food and eating with their children. Sometimes, the messages mothers wanted to portray were framed as being deliberately opposite to the messages they themselves received growing up, or to the attitudes that tended to dominate their own thoughts in this area.

“I just thought, oh as a parent I will just, you know, completely go the opposite direction and be really relaxed around food around my children because, you know, I don't want them to pick this up, I don't want them to pick up habits.” (Victoria)

Some mothers talked about being generally ‘careful’ in terms of what they said about food and eating in their children’s presence, and on occasion ‘biting their tongue’ in response to their children’s eating behaviours. Most commonly, mothers talked about how they would never talk about food as being either ‘good’ or ‘bad’.

“…when I grew up, food was very much good food/bad food: "Oh I'm being very naughty, I'm having cake"—that was the kind of language I grew up with… And so I want to be really, really careful we never talk about good food or bad food. When they say to me "Oh mum I had so much chocolate today" I say "Oh that sounds really delicious, yum". You know, kind of just really… not giving food a moral value.” (Juliet)

While conscious efforts around messaging about food and eating were mentioned by many of the mothers, deliberate messaging in relation to bodies was mentioned to an even greater extent. Mothers wanted their children to have positive relationships with their own bodies, and described great care in how they talked about bodies and weight in conversation with their children, if at all. Some described never commenting on other people’s bodies, or being careful to not use words such as ‘fat’. Several mothers mentioned their efforts to not speak negatively about their own bodies in front of their children.

“I try not to... put myself down in front of them. So I’m really conscious of that… you know, if I’m saying "Oh god I'm so fat, I’m so ugly. Oh I look rubbish in this", then obviously that's going to have an impact, so I really try not to do that.” (Nadia)

The most common strategy mothers described employing was to actively instil body positivity in their children. Many mothers described explaining to their children how people simply come in different bodies, avoiding objectification, and talking about their own and their children’s bodies in terms of health and functionality rather than appearance.

“I don't talk about bodies. If, you know, they mentioned something—"that person's fat, they're big", I say "Yeah they are big, their body is big"… "everyone's different". Kind of just really making it really matter of fact, so that they know that bodies are just bodies. They do amazing things. It does not matter what they look like.” (Juliet)

Mothers believed that children could readily ‘pick up’ attitudes and behaviours in the domains of food, eating and the body, irrespective of whether these attitudes are communicated explicitly. One mother reflected on how, through the process of her eating disorder recovery, she had witnessed a shift in the way her child was also relating to food and his own body:

“And to see even just in my transition and change in attitude, to see how it's changed him and given him more freedom in his body and in his relationship with food, it's been really beautiful to see that. So, I firmly believe as parents we are sending strong messages to our kids whether we realize it or not.” (Hannah)

Several mothers spoke about how they felt it was important to lead by example for their children, but also how this could be challenging in eating disorder-relevant domains. Some mothers described a sense of hypocrisy; of saying things to their children that they didn’t truly believe, or that they felt were true for their children but that didn’t apply to themselves. A small number of mothers mentioned that modelling healthy eating behaviours for their children could subsequently lead to compensatory eating disorder behaviours when their children were not present.

“… a coping thing would be for me to eat normally when the children were around, but to be very disordered in eating when they weren't. So they always saw a good version of me, rather than the one that skips the meals or throws it in the bin or whatever.” (Charlotte)

2b. Looking out for warning signs

Mothers of older children, in particular, spoke about witnessing their children expressing dissatisfaction with their bodies, regardless of gender. Several of these parents also spoke about observing their children displaying difficulties in the domains of food and eating, and witnessing these instances caused great concern.

“… that kid [PARTICIPANT’S SON] was like, you know, losing his… I mean so upset over it and having meltdowns over "I'm fat, I'm fat", and me doing my best to coach him through those conversations for that and just saying like "I totally know what you think or feel"” (Isabel)

“… I caught her a couple of times like hiding [FOOD] to eat. And that for me, it's a red light you know… that's why I was curious about all of this… because at some point even if we don't want to teach them that, they get our anxiety and our stress and the relationship we have with food.” (Catherine)

“…I've noticed her... sort of comfort eating and, you know, she turns to food in the same way I did.” (Georgina)

Some mothers spoke about their heightened awareness of possible signs of eating disorders in their older children, and of ‘keeping an eye’, particularly in response to expressions of discontent with their growing bodies.

“… I do know that he's [PARTICIPANT’S SON] very conscious of what he's putting into his body and what he's doing to make sure that he's, you know, keeping fit. So it is something that, although I don't think would develop, I'm obviously consciously aware that, you know, keep an eye, kind of thing…” (Charlotte)

One mother, whose children were aware of her eating disorder, spoke of how she hoped her adolescent daughter, and her daughter’s friends would see her home as a safe place for food:

“… we've talked about like, if herself or her friends start feeling like there are issues with food, that I'm a safe person that they could talk to… That it doesn't have to get to a point where they need to go into a program, necessarily, but that there's help before that.” (Gabrielle)

2c. Contending with ‘diet culture’

Mothers spoke about how external influences could be detrimental to their concerted efforts to instil body positivity and healthy attitudes to food in their children, and described working hard to counteract these influences. Parenting within a wider ‘diet culture’ was experienced as problematic, where social media, children’s grandparents, peers, and even the school curriculum all presented potential threats to children’s relationships with food and with themselves.

“… I've had to tell him and try to reinforce with him, you know, making those wise choices to help fuel our body and what it means. You know, this can affect our health, we do have to be good stewards of our body. To just try to counteract the messages that he's getting from… not even just my family, but the world at large.” (Hannah)

“He did go through a phase of talking about calories and I think they'd done it at school and that really, really panicked me. Because he started referring to good and bad food, which… I don't like that… 'Cause I think that's sort of the language that I have in my head. So we completely tried to go away from that and say “there's no bad food, it's just…” you know, “it's just food.”” (Amanda)

Theme 3: Communicating about the eating disorder

This theme captures the experiences of mothers around their decisions to tell, or not tell, their children about their eating disorder.

3a. Hiding eating disorder behaviours

Many mothers talked about protecting their children by hiding their eating disorder behaviours from them. Possibly related to the perception that younger children were less impacted and less aware of an eating disorder (see Theme 1), some mothers highlighted how these behaviours were easier to hide when their children were young.

“I think it was easier when they were smaller because they're less aware, they're less observant. You know they would go to bed earlier… when they're little you manage their schedules to such an extent that my behaviours I could have totally to myself... like I would schedule my day—"okay, they do this at these times, I can do what I need to do other times, and nobody knows anything's going on."” (Isabel)

As children grew older, their awareness of their parents’ eating behaviours also grew, and this was often cause for concern. Some mothers spoke specifically about how their children had become aware of - and on occasion explicitly expressed concern about - their parents’ eating behaviours.

“You know [PARTICIPANT’S SON]’s getting a bit older and starting to recognize that I may have little habits around food… perhaps I do need to either think of something else to do, or, be honest with him.” (Victoria)

“… I've been sick their whole life so… I'm sure they've picked up on things that I'm not aware of and, you know, when I went to treatment my daughter was just saying "Yeah I've noticed you haven't really been eating dinner with us anymore" and stuff like that…” (Isabel)

3b. Concerns around talking to children about eating disorders

Several mothers reported they had concerns about the prospect of talking to their children openly about their eating disorder, although often they commented they felt this might become necessary as their children grew older. Mothers expressed conflict around not knowing if disclosure was the ‘right’ thing to do, and concerns that by bringing up the subject, they might be ‘planting a seed’ which could increase their children’s risk of developing an eating disorder.

“I almost don't want to tell them 'cause it's almost suggesting to them that they might have one, or it makes them even think about it. But then I don't want them to struggle with their mental health and not be able to talk to me or not feel like I would understand because they don't know about it.” (Rachel)

For some of the mothers who contemplated disclosing their eating disorder to their children, there was a sense of not knowing how best to do this. One mother reported having received conflicting advice from health professionals about what to tell her child.

“And one of the therapists thought I should be using the word bulimia with her, and then another one got upset about it and said "no", and so I just let it be and went with my gut.” (Gabrielle)

3c. Experiences of talking to children about the eating disorder

Some of the mothers who participated in the study had disclosed their eating disorder to their children. They often highlighted that this was communicated on a level they felt was appropriate for their children’s age, and most described this openness and transparency as having had positive impacts on both their families and themselves.

“I didn't give them all the nitty-gritty details but they knew I had an eating disorder and… I took it as an opportunity to hopefully lead by example for them, that like when you do need help it's okay and, you know, to reach out and so... It was a really good sort of bonding moment for us and my daughter just, sharing that, like, she was proud of me and she was happy, and everyone kind of understood it was me doing what I needed to do for my health.” (Isabel)

“The initial conversation was a little bit awkward, to be honest, 'cause I'm like —how do you explain that to your child? But the interesting thing was, when I explained it on his level... 'cause there's something about explaining it in simple enough terms a child can understand… it gave me a lot of compassion for myself.” (Hannah)

Theme 4: Support needs

This theme refers to the support goals of mothers with eating disorders with regards to their children and breaking cycles of intergenerational transmission, and captures the practical suggestions made by mothers for this support.

4a. Support goals

Mothers spoke about what they hoped could be achieved for their children through support designed specifically for families where a parent has an eating disorder. Mothers desired support that would help them protect their children from developing eating disorders, and enable them to grow up with a healthy relationship with food and an unconditional love of their bodies.

“…so that they don't have sort of disordered eating themselves. So that they can have a healthy relationship with food… it really matters.” (Esther)

“My hope would be that they'd end up being happy and healthy adults… that have a healthy relationship with food, that eat when they're hungry, don't when they're not... and that they kind of have a love of their body, no matter what the size is.” (Gabrielle)

4b. Practical support suggestions

A key area that a number of mothers spoke about concerned difficulties around recognising and teaching their children about healthy, balanced eating, and setting boundaries in this area. Sometimes, this was spoken of in a way that mothers felt was specific to them, perceiving that teaching children to eat healthily might come more ‘naturally’ to parents without eating disorders. Some mothers described a sense of being unsure what a healthy, balanced diet looks like, or what they should or shouldn’t allow their children to eat to ensure their children’s diet remained balanced, and expressed a desire for guidance and support in this area.

“I mean really it's helping our child have a healthy relationship with their own body, and having a healthy relationship with food, because up until the last couple of years I haven't had that, so how can I teach him to have something that I don't have?” (Hannah)

“A lot of times I question myself that I don't know what is healthy, or what, should be said or what's age appropriate. And so just kind of those guidelines as far as like... "This is what should be being said to your [AGE] year old daughter or your [AGE] year old son or your...", you know… Where and when and how does that look is so foreign, but may seem so obvious to other people that grew up in a more normal environment.” (Gabrielle)

Several mothers also expressed a desire for support and guidance around talking to their children about their eating disorder, in age-appropriate ways. Connection to other parents with eating disorders, with whom experiences in this area could be shared, was also mentioned by a small number of participants.

“Support on how to discuss it with children, 'cause I think it is important to talk to them about it, because otherwise it becomes like this elephant in the room. So I think you do need to discuss it with them, in different ways at different ages, as you would with any other illness. Like, you know, if you had cancer, you would be given support about how to talk to your child at different ages about it, and there's no support about that.” (Amanda)

“I'd love to talk to a parent who has explained it to their children.” (Victoria)

Although some had concerns about involving their children in support, often in relation to ‘planting seeds’, a few mothers described a desire for their children to have access to professional support to help them understand their parent’s eating disorder, that would check in on their mental health, and provide access to help at an early stage if needed.

“I also wish there is a way to help them understand me as well 'cause, I find that a worry.” (Lina)

“I think... certainly my children, at the age they were, certainly my son would've benefitted from someone to talk to, who could explain to him what anorexia was. And how it affects people. And how, you know, his mum was still his mum, but she was having difficulties. It didn't mean that I loved him any less, or that I didn't wanna spend time at home. And that, you know, where I was, was to recover. And I, you know, I would recover.” (Charlotte)

Discussion

This study explored the experiences and support needs of mothers with lifetime diagnoses of a range of different eating disorders, including binge eating disorder, and considered parental perspectives around the impacts of an eating disorder on children and how these might differ for children at different ages and of different genders. Within the current report, we have presented our findings concerning maternal perspectives around the impacts of having an eating disorder on children, and in relation to intergenerational transmission specifically. To our knowledge, this is the first study to describe the proactive strategies that mothers with eating disorders may engage in, in efforts to protect their children from developing eating disorders of their own, and their support needs in this regard.

In line with previous research, the present report highlights that, in addition to perceiving a range of indirect impacts of having an eating disorder on their children (e.g. missing out on social activities), mothers with eating disorders describe particular concerns that their children might be impacted in eating disorder-relevant domains (i.e. those relating to food, eating and the body), and fears that they may subsequently go on to develop eating disorders of their own. Whilst these concerns have been reported in previous qualitative research with mothers who have eating disorders [4, 19, 20, 23, 27], our analysis highlights that mothers perceive the impacts of their eating disorder to differ for children of different ages. Tuval-Mashiach et al. [20] previously noted that different attributes of children and different stages of motherhood may prompt different concerns for parents with eating disorders, and Stitt and Reupert noted that the mothers who participated in their qualitative study felt their younger children, specifically, were not impacted by their eating disorder [19]. Our analysis supports the assertion made by Tuval-Mashiach et al. [20], and replicates the finding reported by Stitt and Reupert [19], with the mothers participating in our study also tending to feel that younger children were less impacted by, and/or less aware of their eating disorder. Concerns about eating disorder development appeared to be heightened for mothers who had children approaching adolescence, and this finding highlights the need for more research exploring parental eating disorders in families with older children, particularly in the context of the heightened eating disorder risk associated with this age group.

It is also possible that such maternal perceptions that younger children are less aware and impacted by their eating disorder could contribute to a reduced awareness of unintentional modelling of eating behaviours; a finding previously reported by Martini et al. [37]. Specifically, Martini et al. reported that whilst mothers with and without eating disorders were comparable in relation to the extent of their verbal and behavioural modelling of eating behaviours for their young infants, mothers with eating disorders were less likely to report high unintentional modelling scores. In other words, they appeared to be less aware of times their child exhibited eating behaviours that they engaged in themselves, but that they did not intentionally model [37]. Investigation of whether these low rates of unintentional modelling continue to be reported when children are at an older age may be warranted. Relatedly, as the periods of risk for the intergenerational transmission of eating disorders may be both when children are very young and as they begin to reach puberty [38], additional studies examining the ways parents perceive this risk are now needed, which further examine and compare parental perspectives for children who are at distinct developmental stages.

Just as mental health conditions can be transmitted across generations, so too can parenting itself [8], and whilst the participants in our study were not asked about their own childhoods, many reflected on the food- and body image-related messages they recalled receiving growing up and described efforts to actively parent their own children in ways that are in opposition to these experiences. Relatedly, although mothers were asked about parenting and coping strategies they used for managing their eating disorder in the context of being a parent, they were not specifically asked about their efforts to reduce their children’s eating disorder risk. Yet the mothers in our study described a range of strategies that they consciously employed with the aim of protecting their children from developing body image and eating difficulties. Implementing these strategies is not without challenges, as the mothers in our study described. Although the findings reported by Tuval-Mashiach and colleagues briefly touched on discussion of strategies mothers used to manage challenges of parenthood, such as creating alternative support systems for their children during periods of illness, choosing alternative role models, or providing children with compliments [20], to our knowledge, the strategies parents with eating disorders might employ in efforts to protect their children against developing eating disorders specifically have not been reported similarly previously. These findings highlight the value of conducting qualitative studies, which can offer up new avenues for future research, and we further add to the existing literature by identifying the support needs of mothers, in their own words, in relation to reducing the risk of intergenerational transmission.

In line with the findings of Rørtveit et al. [26] and Tuval-Mashiach et al. [20], and as noted within our third theme which focuses on communicating about eating disorders, mothers described conflicts and concerns around whether or not to disclose their eating disorder to their children which, for many, appeared to be related to children’s increasing age and awareness. Treasure et al. [10] suggest that “prevention is best achieved if there is openness and honesty among all parties” (p. 230). Our results indicate that mothers with eating disorders may value support and guidance to initiate these conversations in age-appropriate ways, without adding to concerns around intergenerational transmission. Relatedly, none of the mothers who participated in our study spoke about genetic risk in relation to their offspring. However, recognition of the genetic factors that are implicated in the intergenerational transmission of eating disorders may help to reduce guilt and self-blame within families affected by parental eating disorders [18]. As such, it may be beneficial to consider incorporating support and guidance that helps parents with eating disorders and their families to understand and acknowledge the complex and multi-faceted nature of intergenerational transmission, when developing preventative programs.

Many of the mothers who participated in our study described witnessing their older children expressing discontent with their bodies, and sometimes engaging in potentially problematic eating behaviours. Relatedly, our analysis raises some important questions about the prevention of eating disorders in children at high familial risk. Specifically, do the deliberate strategies around food and body positivity that the mothers in our study described, and their heightened awareness of early warning signs, ameliorate the increased risk of eating disorders in their children? And how do these strategies differ - or not - to those employed by mothers who do not have eating disorders? Longitudinal and controlled studies will be required to begin to consider these questions, which follow children through and beyond the period of risk for eating disorder onset. Understanding any differences may potentially have important implications not only for our understanding of the mechanisms involved in the intergenerational transmission of eating disorders, but also for the development of distinct parent-based eating disorders prevention programs, for parents with and without eating disorders of their own.

Limitations

Although, on the one hand, we consider the broad range of eating disorder diagnoses and variety of children’s ages as strengths of the present study, it is important to note that, at the same time, the heterogeneity of the sample precluded explicit comparison between parents of younger and older children. Similarly, whilst our analysis did not identify any differences around perspectives on intergenerational transmission between participants with different eating disorder diagnoses, future studies may wish to consider exploring this possibility, given that eating disorder subtypes tend to have distinct presentations, and as they are typically associated with differential course and outcomes [39].

A further limitation of our study is that all of our participants were White mothers from Western countries, and, as a result, our report is not representative of the experiences of parents from other ethnic backgrounds or countries. In addition, although we hoped to recruit both mothers and fathers with eating disorders to our study, only mothers expressed interest in participating. Parents with eating disorders are a seldom-heard group [19]; this is especially the case for fathers. It is also important to note that the mothers who participated were at different stages of recovery, and we did not measure current eating disorder symptomatology. It is possible that perceptions of the impacts of an eating disorder on children may change over the course of recovery. It is also possible that eating disorder symptomatology at a given point in time may influence the extent to which mothers are able to maintain the strategies they described employing in efforts to prevent the development of eating disorders in their children. Some of the mothers who participated in this study, for example, described changes to their parenting during periods of illness, compared to periods of remission [30]. Finally, it is important to acknowledge that mothers were interviewed during the COVID-19 pandemic; an exceptional time which presented a number of challenges for many parents and families [40]. Nevertheless, whilst our questions about the impacts of the pandemic on parenting did not elicit sufficient material of relevance to the focus of our research to be presented in our formal analysis, the impacts of COVID-19 described by the mothers who took part in our study were somewhat varied.

Clinical implications

Whilst further research with larger numbers of parents will be needed to establish the most useful and effective components of support for this group, the support needs identified within our analysis align well with some of the suggested targets of prevention programs for children at familial risk of eating disorders, recently outlined by Levine and Sadeh-Sharvit [18]. Firstly, in addressing established risk factors for eating disorders such as internalisation of the ‘thin ideal’ [18], we propose that in addition to psychoeducation aimed directly at children, such prevention programs may additionally consider providing support and guidance to the parent who has an eating disorder for setting healthy boundaries around food and eating for their children, identifying what a ‘healthy’ diet looks like for children at different ages, and support for parent–child conversations around body image. Secondly, in improving the family’s understanding of the parental eating disorder and how it effects the family [18], we suggest programs may benefit from including guidance and support for parents which acknowledges both genetic risk mechanisms and potentially modifiable environmental factors, and that helps parents to have conversations about eating disorders with their children without exacerbating existing concerns about ‘planting seeds’. Not only could such support potentially contribute to improving children’s outcomes in the long-term, but it could also go some way to helping alleviate some of the prevailing maternal concerns about intergenerational transmission.

Conclusions

For the mothers who participated in our study, concerns about passing on eating disorders to their children are salient. Whilst further research is now needed in order to build upon our initial, preliminary findings, our study suggests that these concerns may become heightened as children reach puberty and begin to articulate their own body images, and that mothers with eating disorders may also take steps to consciously - and conscientiously - manage the messages they explicitly send their children in these domains, and to buffer the messages being received by their children as they grow up within ‘diet culture’. Aware that at times they were engaging in ‘do as I say, not as I do’, the mothers with eating disorders who participated in our study expressed a desire for support largely in the form of practical guidelines to help them to reduce the risk of eating disorders in their children. Such support could be included in preventative programs for children at high familial risk of eating disorders, and even integrated into standard treatments for eating disorders as an add-on option for the substantial number of parents accessing treatment. This additional support could be beneficial not only for mothers with eating disorders, but for their children too.