Family Life Cycle Transitions and the Onset of Eating Disorders: A Retrospective Grounded Theory Approach

Abstract

Aims and Objective

The aim of this retrospective qualitative study is to understand how transitions in the family life cycle and responses to these events may relate to the onset of eating disorders in an attempt to generate new theoretical insights and inform future research in the area of eating disorder prevention.

Background

Little is known about the contextual factors that occur throughout the family life cycle that may be risk factors for the development of eating disorders.

Design and Methods

Semi-structured interviews were conducted with 27 individuals of varied ages (age range =17–64; Median = 27; SD 13.7) currently receiving treatment for eating disorders in an outpatient clinic specialising in eating disorder treatment. Data were analysed using grounded theory methods.

Results

Six themes were identified as family life cycle transitional events that preceded the onset of participants’ eating disorders: (a) School Transitions, (b) Death of a Family Member, (c) Relationship Changes, (d) Home and Job Transitions (e) Illness/Hospitalisation and (f) Abuse, Sexual Assault, or Incest.

Conclusions

Results indicated that transitional events in the family life cycle followed by a lack of needed support during these transitions may precipitate the onset of eating disorders. Thus, future research should use these findings to inform the creation of interventions that reduce the intensity of the stress brought about by these transitional periods and increase the adaptability and coping skills of individuals and family members to prevent eating disorders.

Relevance to Clinical Practice

Nurses and other healthcare professionals should be aware of the importance of transitional events occurring in the family life cycle of adolescents and young adults. Helping parents to be aware and supportive of difficult transitional events may be more important than trying to solve or fix the problem.

INTRODUCTION

Eating disorders among adolescents and young adults are an important public health concern given the negative physical (Herzog et al. 1992, Zipfel et al. 2000) and psychosocial (Johnson et al. 2002) outcomes for individuals and the economic impact of treatment (Brown 2005, Deter & Herzog 1994). Thus, it is important to identify potential risk factors for the development of eating disorders that can inform the creation of interventions and that can assist nurses and other health care professional in providing better care for patients. Focusing on understanding contextual factors that occur throughout the family life cycle that may be risk factors for the development of eating disorders has the potential to provide an informative and useful framework. This approach allows for the identification of transitions during family life cycle developmental stages that may be precipitating factors of eating disorders in a family system, rather than searching for individual behavioral factors as causes of eating disorders.

Research has shown that stressful life events, such as parental divorce or death of a family member or close friend, are associated with disordered eating behaviors such as binge eating and using unhealthy weight control practices, as a way to cope or reduce negative emotions (Loth, et al., 2008, Stice, et al. 1996, Welch et al, 1997). Placing these stressful life events in a family life cycle perspective is important because the majority of eating disorders begin in adolescence when youth are still living in a family (Woodside 1995). Also, being able to identify the family systems’ response to the transitional event will help in understanding the type of family support needed during stressful transitions to prevent eating disorders in adolescent family members. Thus, we propose a study employing qualitative research methodologies to gather rich contextual information directly from individuals affected by eating disorders to understand how family life transitional events and responses to these events may relate to the onset of eating disorders in an attempt to generate new theoretical insights and inform future research in the area of eating disorder prevention.

FAMILY LIFE CYCLE THEORY

Family Life Cycle theory divides the life course of a family into developmental stages that define individuals in the family system. One of the most commonly referenced family life cycle frameworks (Carter & McGoldrick 1989) identifies six normal developmental stages of the family life cycle. These stages are: (a) Leaving Home: The Single Adult, (b) The Joining of Families through Marriage: The New Couple, (c) Families with Young Children, (d) Families with Adolescents, (e) Launching Children and Moving On and (f) Families in Later Life. Each stage has ‘nodal events’, or transitions, that are stress producing and can occur at any time. Transitions can include the loss or addition of family members (naturally or traumatically), relocation of the family through moves or losing a job, or traumatic events experienced by a family member. For example, the loss of a family member through death, or the addition of a family member through marriage, can create stressful transitions that precipitate negative responses in family members. Stress from transitional events is conceptualised to be at its greatest point in the family system when moving between family life cycle stages.(Carter & McGoldrick 1989) Whether the stress results in negative physical or mental health symptoms in the family or in individual family members is dependent on how adaptable the family is and whether there is familial and other support available to transition the family and family members through the event.

Study objective

The objective of this investigation was to explore transitional events during normal developmental family life cycle stages that are perceived by individuals recovering from eating disorders as contributing to the development of eating disorders. Specifically, we sought to answer the following research question: What is the role of transitional events during normal family life cycle developmental stages on the onset of eating disorders, as perceived by individuals recovering from these disorders.

METHODS

Description of study sample

This retrospective qualitative study included 27 individuals (26 females; 1 male). Participants were predominantly white (89%) and ranged in age from 17–64 years (Median=27.0, Mean=34.6, SD 13.7) (Loth et al., 2008). Inclusion criteria were broad; individuals were eligible for the study if they were currently involved in outpatient treatment at the participating eating disorders program and had been in treatment for a minimum of nine months. The average length of time participants had struggled with their eating disorder was 19.6 years (SD 15.3) and the length of eating disorder treatment participants had undergone ranged from 10 months to 18 years. Self-reported eating disorder diagnoses included bulimia nervosa (n=3), anorexia nervosa (n=9), bulimia and anorexia (n=1) or eating disorder not otherwise specified (EDNOS) (n=14).

Recruitment and consent procedures

Participants were recruited through flyers in the waiting area at the outpatient eating disorders treatment facility and via word of mouth. A phone number was provided for interested individuals to call to obtain more information about the study. Those individuals meeting inclusion criteria were given the opportunity to schedule an interview appointment. Participants were given a $30 gift card to a department store to reimburse them for their time.

Ethical considerations

The study was approved by the Institutional Review Board of the University of Minnesota in fall of 2007. Participants were enrolled using IRB approved consent forms and written consent was obtained from participants at the time of the interview. Participants were told orally and through written consent forms that their participation was voluntary and that they could discontinue the interview, or withdraw from the study, at any time. None of the participants discontinued the interview or withdrew from the study. Because of the sensitive nature of participants’ stories, research staff reinforced to participants that their anonymity would be maintained and that the research published from their interview data would be de-identified (also noted in written consent forms).

Interview procedures

Individual, semi-structured interviews with study participants were conducted by the second author in a private room at the eating disorders treatment facility. Questions were piloted on initial interviews; however, no changes were made as the initial interview question guide worked as intended. Probing techniques were used if questions were unclear to the participant and to encourage expansion of responses. Interviews took approximately 45 – 60 minutes and included questions on social and environmental factors hypothesised to have had an influence on the onset of eating disorders. Questions were formulated by the research team with guidance from the literature and use of the ecological framework (Bronfenbrenner 1986). All interviews were audio-taped, transcribed verbatim and reviewed for accuracy. Interview questions are listed in Table 1.

Table 1.

Question guide for semi-structured interviews

I would like to ask you questions about the types of things going on in your life at the time when your eating disorder first presented itself and learn about your ideas for how eating disorders could be prevented.

1. Why don’t you start by telling me about what was going on in your life when your eating disorder first began.

2. When you think back to the time when your eating disorder began, what role did your family play in your life at this time? -What was your relationship like with your parents? -How did your siblings impact your life at this time?

3. We are trying to collect information on how to prevent eating disorders. What is some advise you would give to parents and families to help prevent eating disorders in their families?

4. When you think about the time when your eating disorder first presented itself, what were your relationships with friends like at this time? -What type of support did your relationships provide you with? -What impact, if any, did your friends have on your actions at this time?

5. At the time when your eating disorder first presented itself what were some key school events that were happening in your life? -Were there any sports teams or school events that played a large role in your life at this time? -What impact, if any, did teachers/coaches have on your actions at this time?

6. What is some advice you would have for teachers and school staff that could help them work to make young people feel good about their bodies?

7. A lot of people talk about the media and it’s impact on young people. Do you feel the media had an impact on you during the time when your eating disorder first began? If so, tell me about the impact that the media had.

8. What are some things that you feel work really well to help prevent eating disorders?

9. If you had the ability, what changes would you like to see that would help young people to feel good about their bodies?

10. I have touched on a lot of different things during the interview today, what else have I missed?

11. Out of all of the different things we have talked about during today’s interview, what do you feel is the most important thing to remember when working to prevent eating disorders?

Data analysis

Grounded theory method was used to analyse interview transcripts (Charmaz 2000, Glaser & Strauss 1967, LaRossa 2005, Strauss & Corbine 1998) using NVivo 8 software (QSR, 2007). We used a deductive grounded theory approach which allows the researcher to begin with a research question and hypothesis based on previous literature and theory as a starting point for analysis and generating new theory. Transcripts were coded according to grounded theory method, using three stages of open, axial and selective coding. In the open coding stage, constant comparison using line-by-line coding was conducted to identify broad response categories in each individual transcript. The broad categories were broken into sub-categories during the axial coding stage to organise participant responses by content area and to identify major response themes and concepts. The sub-categories were then examined to identify the contexts in which the themes/concepts operated, the causes and consequences of each theme/concept and how the themes/concepts were related to one another. Next, refinement and specification of themes occurred through focused coding and a coding scheme was developed and applied to sort all transcripts. Through selective coding, centrally relevant concepts that tied the sub-categories together were identified. Six core themes were identified as centrally relevant concepts. Finally, Family Life Cycle Theory was used to organise the themes into transitional events with their corresponding stages in the family life cycle.

The first and third authors independently read and consensed all transcripts. Each transcript was coded twice. Consistency between the two coders, during the stages of coding was assessed using the formula number of agreements/total number of agreements plus disagreements (14). Intercoder reliability was 88%. Further discussion resulted in overall agreement (100%) between the two coders.

RESULTS

Participants identified transitional events that occurred in their lives just prior to the emergence of their eating disorder during two family life cycle stages. These two stages were ‘Families with Adolescents’ or ‘Launching Children and Moving On’ (Carter & McGoldrick, 1989). The six core transitional themes identified by the participants were: (a) School Transitions, (b) Death of a Family Member, (c) Relationship Changes, (d) Home and Job Transitions (e) Illness/Hospitalisation and (f) Abuse/Sexual Assault/Incest. Following the transitional event(s), participants described experiencing a perceived decrease in support or lack of appropriate support from friends and family members. Participants shared that this transitional event, in combination with a lack of appropriate support following the event, were precipitating factors in the emergence of the eating disorder. Over half (55%) of the participants identified two or more overlapping transitional events that preceded the onset of their eating disorder (n = 15). For instance, many participants identified school transitions in addition to another event. Participant experiences are described below. Examples of quotes from individual interviews that exemplify major themes are included in the text and in Table 2. All names and specific identifying information have been changed.

Table 2.

Participant Quotes by Transitional Themes and Family Life Cycle Stage

Family Life Cycle Transitional Theme	Family Life Cycle Stage	Gender	Age	Eating Disorder	Quote:
School Transitions	Families with Adolescents	F	17	AN	“When I started junior high I started having some friend problems, like I had been best friends with two girls and they started to kind of separate themselves from me and I really didn’t know why…that really influenced it [the eating disorder].”
	Launching Children and Moving On	M	19	AN	“Well it [the eating disorder] first started my freshman year in college, a lot of changes started happening in my life. My mentor passed away, my high school coach got sent to Iraq, and I was starting college which is a change in itself…because you don’t receive the daily love that you are used to growing up, you are left to provide that for yourself and I just wasn’t able to do it.”
	Launching Children and Moving On	F	23	AN	“Then I went to college. I was living on my own and that definitely spurred it [the eating disorder] on. I didn’t have anyone to talk to or be with… I would go back and forth between not eating and eating…then I moved into the dorms the next year…with all the changes and feeling alone…I just lost it from there and got really, really bad.”
Death of a Family Member	Families with Adolescents	F	47	EDNOS	When I was 14 there was a close friend of my mother’s that I talked to the most who died. Ever since her death when I had pain, emotional pain…so I used food to numb my feelings…you know, you need an escape and how to deal with things that are hard in life.”
	Families with Adolescents	F	Age Withheld	EDNOS	“When she [mom] died…mostly due to her eating disorder…I was 11 years old…when your mother dies like that, that is something hard to overcome…after she died it became a single parent household, we were given so much freedom with not much emotional support… and too much freedom also from an eating perspective and I lost control.”
	Families with Adolescents	F	23	AN	“My mom died and then it seemed like after that point my eating became erratic, out of stress mainly. I either ate or I didn’t eat. At that point in time people thought that I was loosing too much weight and I started putting myself on the back burner.”
	Families with Adolescents	F	64	EDNOS	“I was 18…the pain from the loss of my son was horrific. For a long time I didn’t have a problem with eating… I was numb…when the numbness wore off I began to have problems with binging. I think it was because I was becoming really depressed because of his death… inside my head I was wishing I was dead and being that depressed you don’t care about anything, so if you have a bad habit of loving donuts you don’t give a damn how many you eat.”
Relationship Changes	Families with Adolescents	F	23	AN/BN	“My parents were divorced and I lived with my mom, and three siblings. My dad got re-married and it was a love and hate relationship with his new wife…she was the perfect Barbie and I was so mad at my dad for choosing her over us… I think that is when my eating disorder really began.”
Home and Job Transitions	Families with Adolescents	F	54	EDNOS	“We moved twice before I was 6 and then at 16 we moved back to the East Coast, that is where we were from originally, so that was hard- it was really hard for me to move at that age. When I got there I just felt lost and my eating problems began.”
	Launching Children and Moving On	F	24	EDNOS	“I got a new job…I didn’t have many friends, I was always too busy. The only friends I had were work friends and they were all older than me, like a lot older than me and couldn’t relate to me. I felt really alone and had no one to talk to or hang out with.”
Illness/Hospitalization	Families with Adolescents	F	19	AN	“I just used the mono [as an excuse] because I did have mono. But the mono was out of my system and I was losing weight for another reason.”
	Launching Children and Moving On	F	49	EDNOS	“I was in for a routine check-up at the doctor…I was told that I had hypo-glycemia and that 50% of people who have hypo-glycemia become diabetic…he told me that I needed to eat frequently and I became obsessed with that and scared that maybe I would die, because that’s what I think of ultimately with diabetes…I started to think constantly about food…I was always figuring out how much I could eat without gaining weight…since then I’ve had a real struggle with bingeing.”
Abuse/Sexual Assault/Incest	Families with Adolescents	F	39	EDNOS	“When my eating disorder began when I was younger, it began because I think it was an outlet for me. With the abuse that went on, it [the eating disorder] progressed and got worse.”
	Launching Children and Moving On	F	27	BN	“…he [boyfriend] was very abusive and very violent. I gained a lot of weight with him, because I thought if I gained the weight then he would leave me alone or I could fight him back. I don’t know what made me stay in that relationship, I really don’t… everyone wanted me to leave and since I didn’t, I had no one to talk to…I know my eating problems really started with him.”
	Launching Children and Moving On	F	23	AN	“…the assault just killed any self liking of my body that I had. It played a significant role in my eating problems.”

Key: M = male, F = female; AN = Anorexia Nervosa, BN = Bulemia Nervosa, EDNOS = Eating Disorder Not Otherwise Specified.

School transitions

Ten participants described leaving home to attend college for the first time as a transitional event. Participants shared that following this move they experienced loss of closeness with high school friends and decreased daily support from family members. Additionally, some participants talked about missing the support they felt in their high school community, including coaches, mentors and teachers. It was following their struggle to adjust to being away from home without the support they were used to that their eating disorder behaviors began to emerge. One participant with anorexia nervosa shared (see Table 2 for more quotes):

I had no identity, no history, nobody knew who I was. I mean I didn’t matter in that [college] environment and I didn’t know how to carve out a place for myself and I was incredibly lonely with no support and I just stopped eating. (26-year-old female)

Eight participants identified going into junior high as a precipitating transitional event prior to the onset of their eating disorder. They described having difficulty leaving the protected environment of elementary school and adapting to the more independent world of junior high. During this transition, participants described difficulties with peer groups and not receiving the support they needed from their family. One participant with anorexia stated (see Table 2 for more quotes):

It [the eating disorder] started when I went into middle school…the change had a big impact on my eating because it was so stressful. Suddenly going from this protected environment where you were in the same classroom all day and then going to multiple different classrooms and teachers and being responsible for your own [self]. (26-year-old female)

Relationship changes

Fifteen participants identified changes in their interpersonal relationships as a transitional event that preceded their eating disorder. Nine participants identified divorce and remarriage of a parent as a stressor preceding the onset of their eating disorder. In particular, participants identified that losing the support from someone who was once so important to them made them feel unimportant or lost. One participant with anorexia nervosa stated (see Table 2 for other quotes):

My dad, he and I were really close in the early part of my life, up until I turned seven years old and he got a girlfriend and she, just overnight, became the most important thing in his life and then I wasn’t, anymore and there was a lot of scary verbal abuse kind of happening… when I would go to stay with my dad his girlfriend would be really mean to me and my dad wouldn’t defend me and that was a complete shift from me being the star and completely daddy’s girl, so it was an overnight – I am not important anymore. (26-year-old female)

Six other participants identified a personal break-up with their boyfriend as the precipitating event that led to their eating disorder. One participant with EDNOS described (see Table 2 for more quotes):

I started a relationship with a guy I was with for five years and during that time things actually were okay… but when we broke up that is when I started to binge. I felt so lonely and lost without him…I would eat out a lot, overeat and that just kind of continued with a period of dieting. (33-year-old female)

Death of a family member

Twelve participants discussed experiencing the transitional event of the death of a family member or close friend prior to the emergence of their eating disorder. Participants shared that they felt uncertain about how to properly cope with the grief they felt and that that they did not feel adequately supported through the grieving process. One participant diagnosed with EDNOS identified (see Table 2 for other quotes):

I had a sister who actually died, when I was five. That event really sort of was traumatic in my family and it wasn’t discussed, like we have never talked about it. The lack of communication and people sort of ignoring this major event, I think, was a big cause of why maybe I started to eat – to compensate for feelings of anxiety. (33-year-old female)

Home and job transitions

Ten participants discussed difficulties inherent to relocation of their family or losing a job as transitional events preceding their eating disorder. They echoed the feelings of other participants by stating that they felt lonely, unsupported and lacked close relationships with friends and family during these transitions. They struggled to cope with these difficult changes in an environment that lacked appropriate and much needed support. One participant with EDNOS shared (see Table 2 for other quotes):

Before it [the eating disorder] all started I transferred from one college to another, went from living in dorms to an apartment and from 1 roommate to 4 roommates. I had also moved home for a little while in between. It was so hectic and I felt like I couldn’t control my life… I didn’t have the support I needed with all of these changes. (23-year-old female)

Illness/hospitalisation

Eight participants described having been ill prior to the onset of their eating disorder. They shared that their illness resulted in unintentional weight loss, which at the time was viewed positively by both themselves and others and then they continued to keep their weight low. One of the participants with EDNOS shared that family members took wonderful care of her while she was ill and she maintained this low weight to be cared for continually. She shared (see Table 2 for other quotes):

I had never had a problem with food before I was sick with viral meningitis. When I was sick I didn’t have an appetite so I really wasn’t eating that much anyways, so I really started to lose weight because I wasn’t eating and then I think I started to get better and then my problem with food started to get worse. I couldn’t control what was happening, like I could die [from meningitis] but I could control what I was eating…subconsciously. I guess I was thinking that if I could be this small, people would kind of take care of things for me. (19-year-old female)

Abuse/sexual assault/incest

Eight participants discussed the transitional event of being victims of traumatic events such as abuse, sexual assault or incest during the time in their lives before their eating disorder developed. Two of these participants described overeating food to ‘become unattractive’ or ‘to become bigger to be intimidating’. It was through this purposeful overeating that their eating disorder first emerged. Participants noted feelings of decreased social support from friends and family and uncertainty with how to properly cope after the abuse/sexual assault. One participant described feeling as though her assault was ‘blown off’ by important people in her life. One participant with EDNOS stated (see Table 2 for more quotes):

…incest from a brother of mine that happened up until I was about 16 played a role in it [the eating disorder]. I think in a way I developed the eating disorder just to get away from it, the pain you know? Just to kill the pain because I couldn’t tell anyone…I had no support. (49-year-old female)

DISCUSSION

The purpose of this retrospective qualitative study was to address the research question: What is the role of transitional events during normal family life cycle developmental stages on the onset of eating disorders, as perceived by individuals recovering from these disorders? Findings identified six specific transitional events in the family life cycle framework that preceded the onset of their eating disorder, as perceived by individuals currently in treatment for eating disorders. The transitional events identified by participants were: (a) School Transitions, (b) Death of a Family Member, (c) Relationship Changes, (d) Home and Job Transitions (e) Illness/Hospitalisation and (f) Abuse/Sexual Assault/Incest. Each of these transitional events were described by participants as ‘factors,’ ‘influences,’ ‘causes,’ or ‘reasons’ for the onset of their eating disorder. Key to the ultimate development of the eating disorder was the participants’ and their family members’ responses to the transitional event. Participants described feeling ‘unsupported,’ ‘lost,’ ‘alone,’ ‘out-of-control,’ ‘horrible,’ ‘unimportant,’ ‘worthless,’ or ‘depressed’ in response to the stress brought on by the transitional event.

According to family life cycle theory (Carter & McGoldrick 1989) stressful transitions, such as the ones found in the current study (e.g. death of a loved one, moving), precipitate adaptive or maladaptive responses from individuals. Whether the stress results in negative physical or mental health symptoms is dependent on the social support available during the transitional event. Thus, adaptability and strong social support is needed to successfully move through challenging transitional events. Findings from the current study suggest that social support from family and friends may be important in helping individuals move through family life cycle transitional events during a critical time in life when youth are at risk for eating disordered behaviors.

Results from the current study support past research that has shown that stressful life events are associated with eating disordered behavior (Loth et al. 2008, Stice et al. 1996, Welch et al. 1997). The results of the current study extend previous research by identifying the role of the family context during transitional events that may increase or decrease the stress experienced by males or females with eating disordered behaviors. Thus, findings from the current analysis indicate that it is important to understand that there are probably many factors that contribute to the onset of eating disorders in adolescents and young adults, some of which include difficult transitions that are an unavoidable part of growing up, and families may be in a unique position to offer the support necessary to navigate these stressful life events and difficult transitions in a successful way.

STUDY STRENGTHS AND LIMITATIONS

This study used qualitative methodology to understand the personal experiences of individuals with eating disorders. Using semi-structured interviews to gather the data allowed us to explore in-depth and report the wide range of individual experiences of participants using their own voices. Using grounded theory methods to analyse the data was also a strength of this study. Grounded theory acknowledges the importance of using theory to guide the research questions, data analysis and interpretation of results.

However, in drawing conclusions from these findings, some limitations must be noted. Because the study population was not representative of all individuals with eating disorders, it is not appropriate to assume generalisability. Additionally, due to retrospective participant formulation of the causes of their eating disorder, it is important to understand that qualitative data gathered from participants cannot necessarily be equated with events exactly as they happened in a participant’s past, but rather events as participants remember and make sense of them.

CONCLUSIONS

Results from the current study suggest that transitional events in the family life cycle followed by a lack of needed support may precipitate the onset of eating disorders. Thus, future research should use these findings to inform the creation of interventions that reduce the intensity of the stress brought about by these transitional periods and increase the adaptability and coping skills of individuals and family members to prevent eating disorders.

RELEVANCE TO CLINICAL PRACTICE.

Nurses and other professionals working in health and mental health care settings should be aware of the importance of transitional events occurring in the family life cycle of adolescents and young adults. It would be important for providers to ask more thoroughly about losses/deaths, school transitions, relationship changes, illnesses/hospitalisations, moves and teasing that are occurring in the lives of young people they treat. Also, reinforcing adaptable responses to these events and referring for help when adequate coping skills and support are not in the resources of the person would be essential to help prevent eating disorders. Finally, it would be important to remind parents of the important role that they can play when their children are going through transitions. Being aware and supportive may be more important than trying to solve or fix the problem.