What parents need to know about the causes of eating disorders

There are many outdated theories about what causes eating disorders. Here’s what you need to know so that you can focus on what matters. If your mum thinks you gave your child an eating disorder, show her this.

This is the whole of Chapter 5 of my book. A longer, earlier version is here, if you want a lot of detail.

This chapter will be brief because you need to concentrate on the powerful actions you can take now, not on what may or may not have caused your child’s eating disorder. My focus is on anorexia, as that’s where the best research on causation currently lies. (For research on causation and a reference to the ‘pack of cards’ metaphor I’m about to use, see the endnotes.[1]) 

Scientists describe the illness is ‘biopsychosocial’: an interaction of biology, psychology and social factors.

I visualise a river that floods because many streams converge. Soil drainage, wind and rain all contribute. There isn’t a single cause.

Or picture life dealing each of us a hand of genetic and environmental. Some increase the risk of anorexia, and some are protective. Many of the genetic cards relate to mental and to metabolic characteristics: anxiety, a high-achieving personality, a drive to move, body fat and insulin function, among many others. There is no single card that determines anorexia. Outcomes are more or less probable, depending on how genes interact with each other – and with the environment.

Take weight loss: environmental cards include eating behaviour, bereavement, and stress. Genetic cards include metabolism. For many people, weight loss is relatively harmless. For our children, though, it’s highly likely to activate anorexia. On the plus side, we expect them to enjoy lasting recovery as long as they keep their weight above a threshold. Epigenetics (how environmental factors dial the effect of genes up or down) may also explain complete recovery: genes that increase the risk of anorexia may get securely turned off.

Consider the 2020 Covid pandemic and its lockdowns. The four-fold rise in anorexia[2] points to a strong environmental factor: without the pandemic, many of the youngsters who flooded clinics might never have developed the illness. But genes were also involved: plenty of desperately unhappy young people did not get anorexia.

In our children, malnourishment (an environmental factor) seems to dial up genes that previously had only a minor effect: we see perfectionism, poor self-esteem, rigidity, black-and-white thinking, depression and anxiety. Nutrition, weight regain – and eventually, recovery – move the dial in the opposite direction: the same genetic traits are then expressed positively. Once recovered, our children shine: they’re often smart, conscientious, high achieving, determined, sensitive and kind.

Resist one-cause explanations

Simple explanations lure us in – even when they’re unfounded. People casually say, ‘Anorexia is the fault of social media’ or ‘It’s all in the genes.’ Outsiders blame the parents, the child, or society – anything that reassures them that, ‘It couldn’t happen to my child!’

Our own thoughts easily turn to self-blame. Some parents worry that they caused the illness by giving free access to ‘junk food’, while others blame themselves for the opposite. Yet while parents agonise about their supposed mistakes, they waste the energy needed to make today’s meals work.

“I wish our therapist had told us what took us so long to find out: ‘This isn't anyone's fault and your child isn't doing this deliberately.’”

It's tempting to see one incident as the cause. Did your child start restricting after a health-promotion talk at school, after finding exercise videos, after being fat-shamed by peers, or after a doctor commented on their BMI? More likely, such incidents were triggers to weight loss, which then led to anorexia because of all the other environmental and genetic factors in play.

Would my daughter have avoided anorexia if her friends had stayed kind? Perhaps, but chances are, some other incident would have tipped her over the edge.

Focus on what you can do, not what you could have done

Family-Based Treatment chooses to be ‘agnostic’ about causation. Clinicians want you to stop ruminating about what you did or didn’t do in the past, and instead attend to the all-important ‘now’. Scientists conduct research on causation, but meanwhile, we need to get on with the best treatments currently available (see Chapter 12). With this agnosticism, FBT differentiates itself from older treatments still in use, which waste months or years searching for supposed ‘root’ psychological causes – such as the harmful notion that parents are to blame.

Many parents begin treatment believing that to cure something, you must first address what caused it. That makes sense with a burst appendix, but it’s not true for many areas of medicine:

“I treat patients with leukemia. I don’t need to know how they got it to treat them.”[3]

What if you know of a cause?

While your child’s eating disorder won’t have a single cause, there may be a factor that stands out – like a major stream feeding a river in flood, or a push that triggers a tipping point. What should you do about it?

Take our example: it was pretty clear that a name-calling incident triggered my daughter’s restriction, which led to weight loss and anorexia. We talked about it, we empathised, we checked that the friendships were restored, and we tried to get her to engage in trauma therapy.[4] None of that provided a fix.

On the other hand, if you know that a causal factor is ongoing, do your best to address it. I speak with parents who changed schools after realising how much bullying was going on. It hasn’t cured the anorexia, but it’s helped bring progress.

Is there a trauma you are aware of? Ask your team to advise whether to help your child with that sooner rather than later. (Chapter 12 has more on psychotherapy as an adjunct to the main treatment.)

Maybe, now that you’re better informed, you regret some of your past actions. Maybe you want to correct things you used to say. When the time feels right, check out the help on expressing regret in Chapter 14. But remember: there is not one cause to this illness, only a cluster of risk factors interacting with each other.

When your child is a lot better, you can spend more time investigating the environmental factors that increase or decrease risk: this will help with relapse prevention (more in Chapter 10). Also recognise that many environmental factors are not under your control. You can’t shield your child from triggers forever. But you can use unfortunate incidents to help them practise self-care skills and grow more resilient.

Your child didn’t choose to have an eating disorder

Your child didn’t choose the cards that life and genes dealt them. Before the illness struck and altered their brain, they’d never have chosen to feel as miserable as they do now. The more we let go of judgement and accept our children as they are, the more we can bring about change. Focus on living and breathing non-judgement and acceptance toward your child, and make that the culture in your household. (More help on unconditional acceptance is in Chapter 14.)

Parents with an eating disorder

Have you suffered from an eating disorder yourself? Do you presently suffer from one but manage to keep it under control? You may fear that therapists will blame you for your child’s illness, or view you as unfit to contribute to the treatment.

First, understand that because of genetics, it’s very common for both child and parent to have – or to have recovered from – an eating disorder.

It’s perfectly appropriate that you care for your child just as any parent would. What matters is what you do now. The trials that validated Family-Based Treatment did not exclude parents with eating disorders. The approach models non-judgement, so you should never feel belittled.

Be mindful of any shame, ambivalence or contradictions within yourself as you get your child to eat and gain weight. This applies to all of us, eating disorder or not, because our environment is saturated with toxic messages about food and weight.[5]

Sometimes, if a parent’s eating disorder is still active, the child’s treatment re-energises it, bringing on extra suffering. If that’s you, you deserve your own support and treatment in parallel.[6]

Extra care is needed around those rarer cases where a parent’s eating disorder drives them to collude with their child’s illness and derail treatment (and that’s the only context in which I approve the word ‘collude’). I once met a teenager whose mother supplied her with laxatives and helped her bin food. Clearly, someone else had to take on the teen’s treatment – in her case, it was her older sister.

Chances are you’ll be a source of great strength and compassion for your child, and you’ll know the art of being both firm and loving.

Why? Why us? How to let go

If you’re losing precious energy asking ‘Why?’ or ‘Why us?’ please know that’s normal. Pause, place a gentle hand on your cheek, and send yourself messages of kindness. You are suffering. It really hurts to imagine you could have done something different. You so want the best for your child. May you find clarity and courage.

Self-compassion will transform the pain better than reading heaps of research. It will move you towards deep acceptance of what is, summarised by this mantra:

“Shit happens.”

The Serenity Prayer

The Serenity Prayer may be more to your taste:

‘Grant me the serenity to accept the things I cannot change, courage to change the things I can, and wisdom to know the difference’[7]

Chapter 15 has more tools to help you with acceptance and letting go. You have limited bandwidth, and guilt and rumination can consume much of it. Redirect your attention and time to what will truly help your child.

Next:

* Go to Chapter 6: Practical steps to help your child beat the eating disorder *

* Go to Table of contents *