Wow! What a thoughtful analysis of these articles! You are absolutely correct – the methodology in both of these studies is quite flawed, which seriously limits our ability to draw definitive conclusions. The definitions of overinvolved and overprotective in these studies are vague and, frankly, pretty stupid. And after further consideration, and a more thorough reading of the studies I cited, which I know I should have done BEFORE I cited them it seems as though there really isn’t any solid evidence demonstrating correlation between helicopter parenting and AN.

Your comment about the Shoebridge study echoes my clinical experience:

“The authors also determined from the records that the mothers of kids who later developed anorexia took their kids to the pediatrician more often than the control mothers did. This is offered as evidence of “overprotection.” What? An explanation just as plausible is that the kids who later developed anorexia actually had more medical problems when they were young than the kids in the control group did. Or that the mothers in the anorexia group were not “overprotective,” but instead the mothers in the control group were “undeprotective” by not taking their kids to the doctor often enough.”

I have observed that parents become more involved and protective of their child when the child develops an ED, cancer, diabetes, asthma, or any other serious illness. Some clinicians may call this “overprotection” or “overinvolvement;” I call it good parenting. Most parents would become anxious and protective of their child and much more involved in her life if she had a mental illness or physical illness.

My observations, which I have derived from my own clinical experience, are obviously biased since my practice naturally attracts a certain “type” of family. I require parents to be fully informed and actively involved their kids’ treatment, so the parents of my adolescent ED patients are, as a rule, extremely involved in their children’s treatment and extremely protective of them. The “underinvolved” or “underprotective” parents probably wouldn’t send their kids to me in the first place. I suspect that many ED professionals have similar experiences with parents, which may explain the presumption that parental involvement and overprotection are correlated with EDs. The less involved, less protective parents don’t bring their children in for ED treatment, so we presume they don’t exist.

The kids I treat almost always have very involved, well-informed, concerned parents who want effective, evidence-based treatment for their children, many of whom travel very long distances or make financial sacrifices to get it. While this may be called “helicopter parenting” by some, I see it as evidence of dedication, love, an excellent prognosis, and I make a point of telling families this at the beginning of treatment. What I find most ironic is that old-school ED professionals perform “parentectomies” or advise parents to back off, which is the PRECISE OPPOSITE of their natural parental instincts to become more involved and more protective when a child is ill. It is also the precise opposite of what empirical research shows us benefits kids the most – active family involvement in treatment and meal support at home.

As I implied by the title of this blog post, I believe that parents who are extremely involved and extremely protective have a lot to offer. I’ve observed that these parents are very valuable members of their child’s treatment team because they are so dedicated to their child’s recovery and so willing to do whatever it takes to help their children. It’s the less-involved, less-protective parents that concern me more. In the end, I guess the nature of the relationship between helicopter parenting and EDs (if such a relationship even exists) is not really important to me, since I don’t base my treatment on this theory. I base my treatment on what has been proven to work. “Show me the science” is a good motto. It’s a shame that so many clinicians base their treatment on the unproven theory that parenting style is related EDs. In my opinion,the most important things are providing evidence-based treatment to all patients and families, and harnessing each family’s unique strengths to help the patient recover.

The Shoebridge paper analyzed the obstetric medical records of 40 mothers of children who later developed anorexia nervosa to try to find evidence to support their hypothesis that overprotective parenting preceded the development of anorexia. Here’s an example of their approach: It turns out that ten of the 40 mothers of kids who later developed anorexia had suffered a previous “severe obstetric loss,” i.e. perinatal or infant death, before the birth of the child who developed anorexia. Those mothers, according to the records, therefore, worried more about miscarriage during the later pregnancy. The authors conclude that this heightened anxiety likely made them overprotective parents later. But there’s no evidence that it actually did. The authors also determined from the records that the mothers of kids who later developed anorexia took their kids to the pediatrician more often than the control mothers did. This is offered as evidence of “overprotection.” What? An explanation just as plausible is that the kids who later developed anorexia actually had more medical problems when they were young than the kids in the control group did. Or that the mothers in the anorexia group were not “overprotective,” but instead the mothers in the control group were “undeprotective” by not taking their kids to the doctor often enough.

Sarah, I agree with you that there is no reliable scientific evidence that “overprotective” or “overcontrolling” behavior by parents cause anorexia nervosa. I go a step further, however. I feel that there is not even reliable evidence of a correlation between the two. In other words, there’s no reliable evidence either that overprotectiveness/overcontrol cause anorexia or that anorexia causes overprotectiveness/overcontrol. The issue matters, in my opinion. As long as clinicians (of which you are not one) are prejudiced and perceive (consciously or unconsciously) that parents of kids with anorexia fit these stereotypes, they will continue to justify their “old school” model of treatment that tries to “remedy” these conditions. That model doesn’t work, it never has, and it is actually insulting to parents because it treats them as stereotypes and caricatures, not as real human beings. And all too often it translates into the advice that parents should not to try to refeed their starving kids, a prescription that is truly unhelpful and dangerous.

Thank you for your response. You pose excellent questions, and I am more than happy to clarify my points and begin a dialogue on this issue.

First, I want to reiterate that there is no reliable scientific evidence that any particular type of parenting causes EDs. I personally believe that parents do not cause EDs, and couldn’t cause them even if they tried. My aims in writing this post were manifold: 1.) To identify the problems associated with helicopter parenting, 2.) To explain the differences between correlation and causation, 3.) To emphasize that parenting style does not cause EDs, 4.) To explain how and why parenting style and EDs may be correlated, even though the former does not cause the latter, and 5.) To point out that helicopter parenting can actually be beneficial in family-based treatment if channeled properly.

There is some evidence from crossectional studies that overprotective and/or over-involved parenting is correlated with AN, which does NOT imply that parenting causes AN. I am aware of two studies which demonstrate that these two variables are correlated. Notably, neither study demonstrated causality:

Horesh et al (1996). Abnormal Psychosocial Situations and Eating Disorders in Adolescence. Journal of the American Academy of Child and Adolescent Psychiatry.

Shoebridge & Gowers (2000). Parental High Concern and Adolescent Onset Anorexia Nervosa: A Case-Control Study to Investigate Direction of Causality. British Journal of Psychiatry.

The Horesh et al study used semi-structured interviews, so the researchers’ questions were standardized to a degree but also allowed for some flexibility in response. Thus, it is quite possible that the researchers’ observations were tainted by their preconceived notions.

The Shoebridge & Gowers study used obstetric records and mothers’ self-reports. It is likely that the mothers’ self-reports were biased in some way. Perhaps they had read somewhere that EDs were associated with overprotectiveness, which resulted in a biased response pattern on the part of the mothers. The obstetric reports are likely to have been more objective, but even so, OB-GYNs, like all human beings, are biased.

The major problem with both of these studies is, of course, the reliance on human interpretation of any kind, whether that is from clinicians, researchers, parents, or children. This is a problem in research – no human being is completely unbiased. Unfortunately, it is very difficult to objectively quantify characteristics like parental involvement or overprotectiveness, and measurement of these traits generally involves some sort of subjectivity on the part of the parent, the clinician, or even the researcher who is completing a standardized questionnaire.

Dr. Janet Treasure of the Maudsley Hospital has done some excellent research on the neurobiological and genetic factors that cause EDs. She has also published books and given lectures on helping the entire family cope with the child’s ED. Her contention is that many families, quite understandably, respond to a child’s ED with increased anxiety, which in turn is manifested in increased involvement and overprotection. This is often the case in families where a child has any serious illness; it is not unique to EDs. Dr. Treasure also asserts that certain styles of interacting amongst family members may serve to reinforce or perpetuate an ED, and that families can and should receive guidance as to how they can work together to overcome unhelpful reactions in order to help their loved one recover.

In sum, the science very clearly indicates that parenting style does not cause EDs. There is some evidence supporting a correlation between helicopter parenting and EDs, although this research is admittedly flawed. Clearly, more rigorous scientific research is needed on this topic.