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Family Functioning in Adolescents with Binge-Eating Disorder

Anne Tetzlaff, Ricarda Schmidt, Anne Brauhardt & Anja Hilbert*
Integrated Research and Treatment Center Adiposity Diseases, Department of Medical Psychology and Medical Sociology, Leipzig University Medical Center,

Objective: While the importance of family factors on the development and maintenance of adolescent anorexia and bulimia nervosa has
been well documented, virtually nothing is known about these impacts in binge-eating disorder (BED). Therefore, this study sought to
examine family functioning (FF) in families of adolescents with BED.
Method: A total of 40 adolescents meeting diagnostic criteria for full-syndrome or sub-threshold BED were compared to 40 matched
adolescents without any eating disorder symptoms (CG). Adolescents’, mothers’, and fathers’ perspectives of various FF components
were assessed using self-report questionnaires.
Results: Adolescents with BED reported significantly less emotionality and affective involvement, and lower adaptability compared to the
CG, although all FF subscales fell within the normal range (T score < 60).
Conclusions: This study provided evidence for decreased FF in families with an adolescent with BED. Further research is needed to
clarify associations between FF and the onset and course of BED. Copyright © 2016 John Wiley & Sons, Ltd and Eating Disorders
Received 26 February 2016; Revised 31 May 2016; Accepted 6 June 2016
Anja Hilbert, PhD, Integrated Research and Treatment Center Adiposity Diseases, Leipzig University Medical Center, Philipp-Rosenthal-Strasse 27, 04103 Leipzig,
Germany. Tel: +49 341 97 15360; Fax: +49 341 97 15359.

Published online 18 July 2016 in Wiley Online Library ( DOI: 10.1002/erv.2462

Introduction and aims Bosmans, 2012) and less caring, more parental overprotection
(Wertheim et al., 1992), and lower family connectedness (Tomori
Various family factors have been identified as risk factors for & Rus-Makovec, 2000). As a pathological and more specific
adolescent anorexia (AN) and bulimia nervosa (BN; Lyke & family factor, higher levels of expressed emotion were recently
Matsen, 2013; McGrane & Carr, 2002). Particularly, family func- found in youth with BED who perceived their mothers as more
tioning (FF), defined as ‘the interactions with family members critical, more emotionally over-involved, and less warm com-
that involve physical, emotional, and psychological activities’ pared with controls (Schmidt, Tetzlaff, & Hilbert, 2015). While
(Commonwealth of Kentucky, 2014), has been found to be expressed emotion is very important for FF and has already been
impaired in families of adolescents with AN and BN compared examined in families of patients with AN and BN (Duclos,
with control families (Holtom-Viesel & Allan, 2014). Relatedly, Vibert, Mattar, & Godart, 2012), it only represents a part of
lower FF was associated with unhealthy weight-related behav- FF. In adults, only one study examined various components of
iours, disordered eating behaviours (Berge et al., 2014), and FF, indicating that families with BED were characterized by less
higher eating disorder psychopathology (Wisotsky et al., 2003) cohesion and expressiveness compared with AN and BN and re-
in non-clinical adolescent samples. When comparing different ported more conflict and control than healthy controls (Hodges,
family perspectives, patients with AN and BN described their Cochrane, & Brewerton, 1998). An observational study in chil-
families as more dysfunctional than one or both parents dren with loss of control (LOC) eating (Czaja, Hartmann, Rief,
(Dancyger, Fornari, Scionti, Wisotsky, & Sunday, 2005; & Hilbert, 2011), a precursor of BED, demonstrated maladaptive
Woodside et al., 1995). However, FF has not been examined communication during family mealtimes when compared with
in adolescents with binge-eating disorder (BED; Tetzlaff & controls.
Hilbert, 2014), recently established as its own diagnostic category This comprehensive investigation of FF in adolescent BED
(APA, 2013). sought to identify differences in FF between families with versus
Binge-eating disorder is characterized by recurrent binge- without BED based on adolescents’, mothers’, and fathers’
eating episodes in the absence of regular inappropriate compensa- reports. According to the literature, we hypothesized that
tory behaviour (APA, 2013) and has been identified in 1.6% of adolescents with BED would report lower FF (more impaired
adolescents in the community (Swanson, Crow, Le Grange, communication, less emotionality, less affective expression, more
Swendsen, & Merikangas, 2011). In children and adolescent control, less cohesion, and less adaptability) than controls.
community samples, binge eating was found to be associated with Further, we hypothesized adolescents with BED to describe their
insecure attachment (Goossens, Braet, Van Durme, Decaluwe, & families’ functioning as more dysfunctional than their own

430 Eur. Eat. Disorders Rev. 24 (2016) 430–433 © 2016 John Wiley & Sons, Ltd and Eating Disorders Association.
A. Tetzlaff et al. Family Functioning in BED

parents, while there would be no differences between family indicating greater disengagement and rigidity respectively
members from the control group (CG). (.71 ≤ α ≤ .79 across family members in this sample).
Data analytic plan
For testing the first hypothesis, a multivariate analysis of vari-
Participants and procedures ance was conducted to examine group differences (BED, CG)
Overall, N = 80 adolescents (12–20 years) were recruited from a in the adolescents’ FS and FACES reports. For the second hy-
randomized-controlled trial offering cognitive-behavioural ther- pothesis, to parse between-participant versus within-participant
apy to adolescents with BED at baseline (Hilbert, 2013) (BED variability while accounting for the nested data design, linear
group; n = 40) and via schools and Internet-based advertisements
(CG; n = 40). The groups were matched by frequency according to
age, sex, body mass index standard deviation score, determined
based on measured weight and height, and socio-economic status. Table 1 Individual and family characteristics
Inclusion criteria for the BED group were a diagnosis of full-
syndrome or sub-threshold BED based on objective and/or sub- BED (n = 40) CG (n = 40)
Test statistics
jective episodes of binge eating according to the Diagnostic and M/n SD/% M/n SD/%
Statistical Manual 4th edition (APA, 2000) and the Diagnostic
and Statistical Manual 5th edition (APA, 2013; refer to Hilbert, Adolescents
Age, years* 14.95 2.49 15.15 2.56 F(1, 79) = 0.13
2013 for more detail). Inclusion in the CG was based on the
BMI-SDS 1.91 0.88 1.77 1.02 F(1, 79) = 0.39
absence of current and lifetime eating disorder symptoms. The Weight status**
exclusion criteria for both groups included current BN, substance Normal weight 11 27.5 16 40.0
χ (2) = 2.28
abuse, suicidal ideation, psychotic or bipolar disorder, serious Overweight 8 20.0 4 10.0
unstable medical problems, intake of antipsychotic or weight- Obese 21 52.5 20 50.0
affecting drugs, psychotherapy, conservative weight loss treat- Sex, female 35 87.5 34 85.0 χ (1) = 0.11
ment, or participation in another treatment trial. Severity of BED***
At the outset of an on-site diagnostic session, written assent was Full-syndrome 30 75.0
obtained from all the adolescents, and for those <18 years, at least Sub-threshold 10 25.0
one parent provided informed consent. The adolescents’ eating Number of binge-eating 11.30 8.38
episodes, monthly
disorder status was obtained using the diagnostic items of the
Duration of BED, months 22.88 25.65
Eating Disorder Examination (Hilbert, Tuschen-Caffier, & Ohms, Mothers
2004). Anthropometric characteristics were objectively measured. Age, years 44.49 6.18 45.40 6.01 F(1, 79) = 0.43
All self-report questionnaires were handed out to participating BMI, kg/m
26.88 7.56 28.71 7.56 F(1, 79) = 1.14
family members. While all mothers participated, the biological Fathers †

father was sometimes unknown or had infrequent contact. There- Age, years 46.95 6.24 47.78 5.83 F(1, 79) = 0.21
fore, stepfathers were asked to participate, if possible. The families BMI, kg/m 27.26 3.69 26.77 4.24 F(1, 79) = 0.17
of the patients with BED were offered treatment free of charge, Families
whereas the families of the control participants were offered Family status
€15 as incentive. The study was approved by the Ethics Commit- Married 15 37.5 17 42.5 χ (5) = 5.17
Unmarried 3 7.5 3 7.5
tee of the Medical Faculty of the University of Leipzig, Germany.
Separated/Divorced 20 50.0 15 37.5
Widowed 0 0.0 4 10.0
Measures Father’s living situation†
Father in household 23 57.5 25 75.8 χ (1) = 2.68
The Family Scales (FS; German version: Familienbögen; Cierpka
Father not in household 17 42.5 8 24.2
& Frevert, 1994), a translated and advanced version of the Family
Assessment Measure (Skinner, Steinhauer, & Santa-Barbara, Low SES 7 17.5 10 25.0
χ (3) = 0.86
1983), were administered to assess four components of FF: Middle SES 16 40.0 14 35.0
communication, emotionality, affective involvement, and High SES 14 35.0 14 35.0
conflict. The FS have acceptable to good psychometric properties
(.70 ≤ α ≤ .83 across family members in this sample), and norms Note: BMI-SDS, standard deviation score of the body mass index; BMI, body mass
are available (Cierpka & Frevert, 1994). The items were rated index (kg/m ); SES, socio-economic status (Winkler social class index); BED,
from 0 = strongly disagree to 3 = strongly agree. For the subscales, binge-eating disorder; CG, control group. Because of missing data, percentages
may not add up to 100%.
sum scores were computed and transformed into T scores, with
*Age range 12 to 20 years in both groups.
T scores ≥60 indicating low FF and T scores <60 indicating FF
**Normal weight = 1.28 < BMI-SDS < 1.28; overweight = BMI-SDS ≤ 1.28; obese
as being within the normal range. = BMI-SDS ≤ 1.88.
The Family Adaptability and Cohesion Evaluation Scales III ***Full-syndrome, BED according to DSM-IV-TR or DSM-5 (objective and/or
(FACES; Olson, 1985) were used to assess adaptability and cohe- subjective episodes); sub-threshold, BED (of low frequency and/or limited
sion. Sum scores for both subscales were computed (items rated duration) according to DSM-5.

from 0 = almost never to 5 = almost always), with lower scores BED group n = 22, CG n = 28.

Eur. Eat. Disorders Rev. 24 (2016) 430–433 © 2016 John Wiley & Sons, Ltd and Eating Disorders Association. 431
Family Functioning in BED A. Tetzlaff et al.

mixed models (LMMs) of Group (BED, CG) × Member (adoles- Discussion

cent, mother, father) and their interaction were used for each
subscale. Members were hierarchically nested within families. For the first time, this study examined FF in youth with BED.
Because of the correlated nature of repeated measure data and Consistent with previous findings in adult BED and adolescent
different variances between members, an unstructured covari- AN and BN (Hodges et al., 1998; Casper & Troiani, 2001;
ance structure was assumed. For additional analyses, Pearson McDermott, Batik, Roberts, & Gibbon, 2002), youth with BED
correlation coefficients were used to determine the associations displayed a specific pattern of decreased FF when considering
between the adolescents’ age, sex, BED subtype (full syndrome adolescents’ perspectives only. As hypothesized, they reported
or sub-threshold), number of binge-eating episodes, duration significantly less emotionality and affective involvement and lower
of BED, and each FF subscale. adaptability than the controls without any eating disorder symp-
Statistical analyses were performed using SPSS 20.0. Signifi- toms. Against expectation and in contrast to findings in AN and
cance was set at a two-tailed α <.05. BN (Dancyger et al., 2005; Woodside et al., 1995), the FF ratings
in the families with BED fell within the normal range of FF, sug-
gesting that the families with BED are more likely to report
healthy FF compared with those with other eating disorders.
By design, the BED group and the CG did not differ in Notably, although the families reported a healthy level of FF on
sociodemographic and anthropometric variables (all p > .05; refer average, some families with BED are suggested to exhibit dysfunc-
to Table 1). tional levels of FF.
The adolescents with BED differed significantly on the FF sub- Importantly, all family members of the adolescents with BED
scales from the CG (F(6, 73) = 2.39, p = .04, η2 = 0.16). In univar- reported less emotionality than the CG families. Thus, reduced
iate analyses, the adolescents with BED reported significantly affective expression (e.g. regarding content, intensity, or timing)
higher FS emotionality (F(1, 79) = 4.97, p = .03, η2 = 0.06), FS seems to be a noteworthy family factor in BED (Hodges et al.,
affective involvement (F(1, 79) = 4.16, p = .04, η2 = 0.05), and 1998), as found in AN and BN (Shisslak, McKeon, & Crago,
lower FACES adaptability than the CG (F(1,79) = 6.13, p = .02, 1990), and in associations between BED and expressed emotion
η2 = 0.07; refer to Table 2). Differences on FACES cohesion were (Schmidt et al., 2015). Closely linked to affective expression and
on trend level (F(1, 79) = 3.21, p = .08, η2 = 0.04). in line with findings in AN and BN (Waller, Calam, & Slade,
The LMM on FS emotionality revealed a significant main effect 1989), the adolescents with BED reported less affective involve-
of group (p = .03; refer to Table 2). An interaction effect of ment than the controls, suggesting difficulties in the family to
Group × Member for FACES adaptability indicated significantly meet family members’ emotional and security needs and a lack
lower adaptability in the adolescents with BED compared with of flexibility for family members’ autonomy. Similarly, the adoles-
the CG (p = .006). The LMMs on FS communication, affective cents with BED reported lower adaptability than the CG, indicat-
involvement, and control revealed a significant effect of member ing difficulties of the family system to change its structure in
(p < .05). Follow-up analyses indicated that the adolescents’ response to situational and developmental stress (Olson, 1985).
reports on these subscales were more positive than the parents’ While the tendency of lower cohesion in adolescents with versus
reports (p < .05). without BED is consistent with previous findings in adult BED
Additional analyses showed that FF was not significantly (Hodges et al., 1998), the results did not reveal impaired commu-
associated with the adolescents’ age, sex, BED subtype, number nication and more control in BED versus CG families, contrary to
of binge-eating episodes, and duration of BED, although expectations. Healthy levels of communication and control might
small-to-medium effect sizes were found (r = .14–.34; all be valuable resources for a family to overcome with more dys-
p > .05). functional FF components. The fact that both adolescents with

Table 2 Descriptive statistics and linear mixed modelling (LMM) of family functioning in families of adolescents with (BED) versus without (CG) binge-eating disorder

Adolescents Mothers Fathers LMM

BED (n = 40) CG (n = 40) BED (n = 40) CG (n = 40) BED (n = 22) CG (n = 28) Group Member Group × Member

FS subscales
Communication 49 ± 13 46 ± 11 54 ± 12 51 ± 13 55 ± 13 50 ± 12 F(1, 81) = 3.21* F(1, 137) = 7.59*** F(1, 137) = 0.48
Emotionality 53 ± 12 48 ± 10 56 ± 13 52 ± 14 53 ± 13 51 ± 11 F(1, 79) = 4.89** F(1, 134) = 2.52* F(1, 134) = 0.09
Affective involvement 49 ± 12 44 ± 10 52 ± 11 52 ± 12 53 ± 11 52 ± 12 F(1, 84) = 1.39 F(1, 139) = 10.35† F(1, 139) = 1.28
Control 46 ± 9 45 ± 10 50 ± 10 49 ± 11 49 ± 11 52 ± 13 F(1, 86) = 0.02 F(1, 144) = 4.87*** F(1, 144) = 0.64
FACES subscales
Cohesion 30.10 ± 5.79 32.23 ± 4.76 30.82 ± 3.78 31.67 ± 4.80 29.75 ± 4.59 30.04 ± 4.88 F(1, 79) = 1.95 F(1, 133) = 1.90 F(1, 133) = 0.78
Adaptability 25.90 ± 4.98 28.80 ± 5.49 26.97 ± 4.30 26.51 ± 4.35 26.65 ± 4.17 26.29 ± 4.39 F(1, 80) = 0.98 F(1, 137) = 0.85 F(1, 137) = 3.52**

Note: BED, binge-eating disorder; CG, control group; FS, Family Scales: T scores ≥60 indicate low FF, and T scores <60 indicate FF as being within the normal range; FACES,
lower sum scores indicate greater disengagement (cohesion) and rigidity (adaptability); LMM, linear mixed model.
*p < .10.**p < .05.***p < .01.†p < .001.

432 Eur. Eat. Disorders Rev. 24 (2016) 430–433 © 2016 John Wiley & Sons, Ltd and Eating Disorders Association.
A. Tetzlaff et al. Family Functioning in BED

and without BED reported their families as more functional than As self-reports might provide subjective and socially required per-
their parents could be influenced by parental problems with the spectives, clinicians should be attentive to observable family inter-
adolescents’ increased emotional distance, conflict, and behav- actions that may indicate dysfunctional FF. Because the present
ioural autonomy in puberty (Steinberg, 1987). study assessed general interactions and attitudes in families,
With respect to limitations of this preliminary investigation of disorder-specific FF, such as interactions during meals (cf. Czaja
FF in adolescent BED, the cross-sectional design did not allow et al., 2011), could be more dysfunctional, and therefore should
for causal conclusions. The generalizability of findings is limited be further considered. As the gold standard of treatment of ado-
by the use of self-report measures of FF only, comparison of lescent BED is not yet clear, research would also help to evaluate
treatment-seeking and non-treatment seeking groups, and the the need for family-based intervention in adolescent BED.
oversampling of female adolescents. Finally, because the fathers’
availability was limited in the BED sample, the results on the Acknowledgements
family members’ views of FF should be interpreted with caution.
Further research is needed to clarify associations between FF This work was supported by the Federal Ministry of Education
and binge-eating behaviours using longitudinal designs as well and Research (BMBF), Germany, FKZ: 01EO1001. No author of
as experimental and interview-based methods for assessing FF. this manuscript has any conflicts of interest.

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