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. Author manuscript; available in PMC: 2022 Dec 1.
Published in final edited form as: Addict Behav. 2021 Aug 17;123:107089. doi: 10.1016/j.addbeh.2021.107089

Double trouble? Associations of parental substance use and eating behaviors with pediatric disordered eating

Rebecca G Boswell 1,2, Janet A Lydecker 1
PMCID: PMC8506907  NIHMSID: NIHMS1735405  PMID: 34450350

Abstract

Objective:

Comorbidity between substance use disorders and eating disorders is common and related to severity of psychopathology. Parents’ eating disorder or substance use disorder have been examined independently and appear to be related to psychopathology in their children. However, no prior work has examined whether co-occurring substance use and eating disorder behaviors in parents relate to eating-disorder psychopathology and weight in their children.

Method:

Participants (N=435) were parents who completed an online cross-sectional survey. Parents reported their personal substance use and eating-disorder behaviors. Relationships between parental substance use (SUD), parental binge eating (ED), and co-occurring parental substance use and binge eating (SUDxED) with child eating-disorder psychopathology and weight were examined using linear regression. Parent age and sex, child age and sex, parent impulsivity and parent depression scores were included as covariates in analyses.

Results:

Greater severity of co-occurring parental SUDxED behavior was associated with greater child eating-related psychopathology, including child binge eating and child purging. Additionally, greater parental binge eating (ED) alone was associated with greater child binge eating and overeating. Parental SUD and/or ED behavior were not related to child weight. Child age did not moderate relationships between parent SUDxED behaviors and child binge eating or overeating.

Discussion:

Overall, parents with greater co-occurring substance use and eating disorder behaviors had children with more severe eating-disorder psychopathology. Clinicians working with families, and those seeking to prevent pediatric eating-related problems, should consider assessing and addressing parents’ psychopathology to improve prevention and treatment efforts.

Keywords: parents, eating disorder, substance use, binge eating, comorbidity

1. Introduction

Parents’ personal eating-related psychopathology confers risk for eating psychopathology in their children. Across studies, children of parents with eating disorders have more physical and psychological health problems, including greater incidence of eating disorders (ED; Watson, O’Brien, & Sadeh-Sharvit, 2018). Family weight and eating concerns are associated with heightened risk for binge-eating disorder, bulimia nervosa, and anorexia nervosa (Hilbert et al., 2014). Recent work has shown that parental eating disorders are associated with child eating-related psychopathology (Lydecker & Grilo, 2016). Moreover, parental binge eating, to a greater extent than parental weight status, is associated with binge-eating behavior in their children (Lydecker & Grilo, 2017).

In parallel, parents’ personal substance use is related to increased risk for negative outcomes in their children. Parental substance use disorder (SUD) is prospectively associated with SUD in their children (Clark, Cornelius, Wood, & Vanyukov, 2004; McLaughlin et al., 2012). Indeed, parental SUD is associated with broadly-defined child impairment, including increased rates of psychological and medical health problems (Smith, Wilson, & Committee on Substance Use and Prevention, 2016).

There is substantial comorbidity between SUD and ED in adults (Bahji et al., 2019). This overlap is likely due to shared neurobiological, psychological, and social factors. One such factor is impulsivity, a multidimensional construct that reflects a tendency towards reward-seeking behavior (Dawe & Loxton, 2004). The mesocorticolimbic dopamine system underlies reward-related and impulsive behavior; this system is related to both substance and eating-related conditions (Bari & Robbins, 2013; Volkow, Wang, Tomasi, & Baler, 2013) and is influenced by heritable factors (Bezdjian, Baker, & Tuvblad, 2011; Elam et al., 2016; Rapuano et al., 2017). Compared to adults with ED only, adults with comorbid eating and impulse-control difficulties report heightened impulsivity (Boswell & Grilo, 2020). Accordingly, heightened impulsivity may be a common transdiagnostic risk factor that underlies ED, SUD, and comorbidity between these conditions.

In addition to impulsivity, severity of parent psychopathology may be associated with heightened risk for psychopathology in their children. Comorbidity between eating disorders and substance-related problems indicates more severe psychopathology in adults (Bahji et al., 2019; Becker & Grilo, 2015; Boswell & Grilo, 2020; Claudat et al., 2020; Waxman, 2009) and adolescents (Castro-Fornieles et al., 2010). Moreover, severity of parental depression is associated with elevated risk of child psychopathology, including depression and SUD (Lieb, Isensee, Höfler, Pfister, & Wittchen, 2002). Thus, heightened parental clinical severity, reflected in parental comorbidity, may broadly increase risk to their children.

To date, a limited literature has examined whether SUD or ED in parents is related to increased eating psychopathology in children, but no studies have examined their co-occurrence in parents. In a large nationally-representative sample, family history of alcoholism was associated with greater risk for pediatric obesity (Grucza et al., 2010). In a multi-site study examining risk factors for ED, parental SUD was associated with increased risk for binge-eating disorder, bulimia nervosa, and anorexia nervosa (Hilbert et al., 2014). Consistent with the conceptualization that impulsivity has a transdiagnostic association with both SUD and eating-related problems, parental substance use is associated with greater reward-driven eating behaviors in children (Cummings et al., 2020) and greater sensitivity in brain regions implicated in monetary and food reward in adolescents (Stice & Yokum, 2014).

Identifying factors associated with pediatric eating-disorder psychopathology is important for identifying intervention targets for prevention and treatment programs. However, no prior work has examined whether co-occurring parental eating and substance use problems are associated with greater eating-disorder psychopathology in their children. To address this gap in the literature, we investigated whether greater parental SUD behaviors, parental ED behaviors, and/or the interaction of parental SUD and ED behaviors (SUDxED) were associated with increased severity of eating and weight problems in their children. We hypothesized that children of parents with greater combined SUDxED behaviors would have more severe eating-related psychopathology and higher weight, independent of other parental comorbidity (i.e., depression, impulsivity). Additionally, we hypothesized that children of parents with ED behaviors, moreso than parents with SUD behaviors, would have greater eating-related psychopathology and higher weight.

2. Methods

2.1. Procedures

Survey respondents (N=435) were recruited from Amazon Mechanical Turk (MTurk). Individuals responded to an advertisement to complete an online survey on “parents’ opinions about weight and eating” and they were eligible if they were adults, in the United States, proficient in English, and the primary caregiver (i.e., child lives in the home more than half the time) of a child between the ages of 5 and 15 years. Participants were included in the current study if they answered questions about their personal substance use and eating disorder behaviors. MTurk has been used reliably for research studies (Behrend, Sharek, Meade, & Wiebe, 2011; Buhrmester, Kwang, & Gosling, 2011), including for eating-related (Boswell, Sun, Suzuki, & Kober, 2018) and substance use-related work (Vanderbroek, Acker, Palmer, De Wit, & MacKillop, 2016).

The current study used the quality control measures provided by the Mechanical Turk platform (approval rating exceeding 85%, location in the United States, duplicate surveys disallowed) and included attention and validity challenges using varied response formats and spaced throughout the survey; data with failed challenges were excluded. This study was approved by the Yale School of Medicine institutional review board; all participants provided online informed consent prior to completing surveys. Data are available from the senior author upon reasonable request.

2.2. Participants

Participants (N=435) were predominantly White (91.6%), non-Hispanic (92.4%), female (79.2%), biological parents (92.4%) who had completed at least some college (92.1%). While completing survey measures, parents were instructed to think about the child who they were most concerned about in terms of their eating, weight, or body image. Parents reported that 52.1% of children were male and 47.9% were female. Mean parent age was 37.03 (SD: 7.91; Range: 21–64) and mean child age was 9.65 years (SD: 2.84; Range: 5–15); mean parent BMI was 27.73 (SD: 6.95; Range: 16.64 – 60.22) and mean child BMI-for-age percentile was 63.52 (SD: 33.61; Range: 0.00 – 99.96).

2.3. Measures

Parents reported demographic information about themselves and their child and completed questionnaire measures. Self-reported height and weight were used to calculate parent BMI. Parent-reported child height and weight were used to calculate child BMI-for-age percentile scores using age- and sex-based norms. Although reported and measured anthropometric data are consistently highly correlated, reported data have higher height and lower weight compared to measured values (Gorber, Tremblay, Moher, & Gorber, 2007); discrepancy between reported and measured height and weight have been shown to be unrelated to eating psychopathology (White, Masheb, & Grilo, 2010).

2.3.1. Alcohol, Smoking, and Substance Involvement Screening Test (ASSIST; WHO ASSIST Working Group, 2002).

The ASSIST is a well-validated and reliable 8-item SUD screening test established by the World Health Organization, which measures the risk of problems associated with reported use of illicit or non-prescribed substances (e.g., alcohol, cocaine, opiates, marijuana, amphetamines, hallucinogens). The ASSIST queries about (1) lifetime use of substances; (2) frequency of substance use (e.g., “In the past three months, how often have you used the substance?”- never (0), once or twice (2), monthly (3), weekly (4), almost daily/daily (6)); (3) frequency of strong craving to use substances; (4) frequency of health, social, legal, or financial problems related to substance use; (5) frequency of interference with role responsibilities; (6) concern from others about use; (7) failures to control use; and (8) route of administration. For each substance endorsed, a risk score is computed by summing responses global scores (range:0–39) to indicate risk of substance-related problems: for alcohol, a score of 0–10 constitutes low risk, 11–26 moderate risk, and 27+ high risk, and for all other drugs, a score of 0–3 constitutes low risk, 4–26 moderate risk, and 27+ high risk. A total global risk score is computed by summing across substances.

2.3.2. Eating Disorder Examination Questionnaire (EDEQ; Fairburn & Beglin, 1994).

The EDEQ measures cognitive and behavioral aspects of eating-disorder psychopathology. Parents completed the EDEQ regarding their own behavior over the past 28 days. The current study used a brief version of the EDEQ, which uses seven cognitive items from the full version to derive three subscales and sum to a Global score (Dietary Restraint [3 items; e.g., “Have you been deliberately trying to limit the amount of food you eat to influence your weight or shape (whether or not you succeeded)?”], Overvaluation [2 items; e.g., “Has your weight or shape influenced how you think about (judge) yourself as a person?”], and Dissatisfaction [2 items; e.g., “How dissatisfied have you been with your weight or shape?”]; higher scores are indicative of greater severity). This brief version has been shown to demonstrate superior psychometric properties to the original measure in a variety of samples (Machado, Grilo, & Crosby, 2018; Machado, Grilo, Rodrigues, Vaz, & Crosby, 2020) and demonstrated reliability in the current study (α=.79-.90). Behavioral items include frequency of overeating episodes (OOEs), objective binge-eating episodes (OBEs), and purging episodes.

2.3.3. Eating Disorder Examination Questionnaire- Parenting Version (EDEQ-PV; e.g., Lydecker & Grilo, 2016).

EDEQ-PV is a “parenting” version of the EDEQ which measured parent concern about their child’s eating/weight (e.g., “Have you had a definite fear that your child would lose control over eating?”). This measure included parent report of the frequency of child eating disorder behaviors in the past 28 days (OOEs, OBEs, and purging episodes). The EDEQ-PV was internally consistent in the current sample, α=.66-.95. Further, parent report of child eating behaviors has acceptable convergence with clinical interview of eating behaviors (Elliott, Tanofsky-Kraff, & Mirza, 2013; Steinberg et al., 2004) and fair agreement with adolescent report (Bartholdy et al., 2017).

2.3.4. Barratt Impulsiveness Scale (BIS-11; Patton, Stanford, & Barratt, 1995; Stanford et al., 2009).

BIS-11 is a widely-utilized, well-validated, and reliable 30-item measure of impulsivity in attention, motor, and non-planning domains. The BIS assesses cognitive/behavioral aspects of impulsivity (e.g., “I act on the spur of the moment”; “I am future oriented”-reverse scored) via 4-point Likert scale (Rarely/Never–Almost Always/Always). Items are summed to create a global score that indicates overall levels of impulsivity (in current sample, α=.87).

2.3.5. Patient Health Questionnaire (PHQ-9; Kroenke, Spitzer, Williams, & Lowe, 2010; Spitzer, Kroenke, & Williams, 1999).

PHQ-9 is a well-established 9-item measure of depressive symptoms with excellent criterion validity, internal consistency, and test-retest reliability (Kroenke, Spitzer, Williams, & Lowe, 2010). Items are summed to indicate severity of depressive symptoms (range:0–27; in current sample, α=.94).

2.4. Statistical Analyses

Parent SUD and ED Behaviors.

Parent substance use behaviors were defined continuously using the global risk score from the ASSIST. In parallel, parent eating disorder behavior was characterized continuously via self-reported binge eating (OBEs) from the EDE-Q. Co-occurring parental substance use and eating disorder behaviors (SUDxED) were specified using an interaction term computed from parent SUD and ED behavior variables.

Regression Models.

Linear regression models were used to examine the extent to which severity of parent SUD behaviors, parent ED behaviors, and parent SUDxED behaviors were associated with eating and weight problems in their children. Predictor variables included parent SUD behaviors, parent ED behaviors, and the interaction between parent SUDxED behaviors, as well as child age and sex, parent age and sex, parent depression, and parent impulsivity. Separate models were used for each outcome variable (child clinical characteristics: child OBE, child purging, child OOE, child BMI-for-age percentile). In all analyses, child OOEs, OBEs, and purging frequency were log-transformed to adjust for variable skew (Table 3S). Both predictor and outcome variables were mean centered. Significant interactions between parent SUDxED behaviors were further investigated using simple slopes analysis with points one standard deviation above and below the mean for predictor variables. Given the role of child development in eating disorder onset, when child age was significant in initial regression models, moderation by child age was examined using the PROCESS macro (Hayes, 2017).

Correlation Analyses.

Pearson’s correlations examined the relationships between parent clinical characteristic variables (parent OBEs, substance use, depression, impulsivity) and child clinical characteristic variables (child OBE, purging, OOE, BMI-for-age percentile).

3. Results

3.1. Parent SUD/ED Severity and Child Clinical Characteristics.

3.1.2. Child OBEs

There was a significant interaction between parent SUD and ED behaviors, which reflected that parents with greater SUD and greater ED behaviors reported more child binge eating (SUDxED: β=.21, p< .001; Figure 1A). Parent ED behaviors alone were significantly associated with greater child OBEs (β=.19, p<.001), but parent SUD behaviors alone were not (β=.004, p=.06; Table 1). Child age (β=.13, p=.01) and parent depression (β=.16, p=.002) were also associated with greater child OBEs; parent age, parent sex, parent impulsivity, and child sex were not significant (ps>.06). Child age did not moderate the relationship between dual parent SUDxED behaviors and child OBEs (r2=.002, F(1,418)=1.19, p=.28).

Figure 1.

Figure 1

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Table 1.

Parent SUD/ED Severity and Child Eating Psychopathology.

Child OBE Child Purging
beta SE St. B t p beta SE St. B t p
Parent Age 0.01 0.004 0.06 1.20 0.23 −0.002 0.002 −0.05 −0.83 0.41
Parent Sex −0.02 0.07 −0.01 −0.31 0.76 −0.02 0.03 −0.03 −0.58 0.56
Child Age 0.002 0.001 0.13 2.48 0.01 0.000 0.000 0.02 0.40 0.69
Child Sex 0.03 0.06 0.03 0.57 0.57 −0.007 0.027 −0.01 −0.26 0.80
Parent Impulsivity 0.000 0.003 −0.01 −0.17 0.87 −0.003 0.001 −0.12 −2.22 0.03
Parent Depression 0.02 0.01 0.16 3.06 0.002 0.01 0.003 0.25 4.47 <.001
Parent SUD 0.004 0.002 0.11 1.86 0.06 0.003 0.001 0.14 2.31 0.02
Parent ED 0.14 0.03 0.19 4.13 < .001 7.53E-05 0.016 0.00 0.01 0.99
Parent SUDxED 0.01 0.002 0.21 3.74 < .001 0.004 0.001 0.19 3.23 0.001
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Note. Linear regression model. OBE = objective binge episode; SUD = substance use disorder behaviors; ED = eating disorder behaviors (i.e., binge eating); SUDxED = interaction between SUD and ED behaviors. All variables were mean centered; bold indicates significant results. Beta = unstandardized coefficient; SE = standard error; St. B = standardized coefficient.

3.1.3. Child Purging

A significant interaction between parent SUD and ED behaviors reflected that parents with greater SUD and greater ED behaviors reported more child purging (SUDxED: β=.19, p =.001; Figure 1B). Parent SUD behaviors alone were associated with greater child purging (β=.14, p=.02), but parent ED behaviors alone were not (β=.000, p =.99; Table 1). Parent impulsivity was associated with less child purging (β=−.12, p=.01) and parent depression was associated with greater child purging (β=.25, p<.001). Parent and child age and sex were not significant (ps>.41).

3.1.4. Child OOEs

Parent ED behaviors alone were significantly associated with greater child OOEs (β=.23, p<.001), but parent SUD behaviors were not (β=.11, p=.08; Table 2). There was no significant interaction of parent SUDxED behaviors on child overeating (p=.60). Child age was associated with greater child OOEs (β=.16, p=.003). Child age did not moderate the relationship between parent ED behaviors and child OOEs (r2=.007, F(1,418)=3.50, p=.06). Other variables were not significant (ps>.08).

Table 2.

Parent SUD/ED Severity and Child Eating and Weight.

Child OOE Child BMI-for-age percentile
beta SE St. B t p beta SE St. B t p
Parent Age 0.002 0.01 0.02 0.33 0.74 0.11 0.25 0.03 0.44 0.66
Parent Sex −0.04 0.10 −0.02 −0.42 0.67 −4.38 4.15 −0.05 −1.06 0.29
Child Age 0.004 0.001 0.16 2.98 0.003 0.05 0.06 0.05 0.87 0.39
Child Sex −0.02 0.08 −0.01 −0.21 0.83 −1.78 3.29 −0.03 −0.54 0.59
Parent Impulsivity 0.001 0.004 0.02 0.36 0.72 −0.10 0.16 −0.04 −0.62 0.54
Parent Depression 0.01 0.007 0.09 1.64 0.10 0.26 0.32 0.05 0.82 0.42
Parent SUD 0.01 0.003 0.11 1.75 0.08 0.09 0.14 0.04 0.66 0.51
Parent ED 0.21 0.05 0.23 4.60 <.001 −0.16 1.98 0.00 −0.08 0.94
Parent SUDxED 0.002 0.003 0.03 0.53 0.60 0.19 0.14 0.08 1.32 0.19
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Note. Linear regression model. OOE = overeating episode; SUD = substance use disorder behaviors; ED = eating disorder behaviors (i.e., binge eating); SUDxED = interaction between SUD and ED behaviors; BMI = body mass index. All variables were mean centered; bold indicates significant results. Beta = unstandardized coefficient; SE = standard error; St. B = standardized coefficient.

3.1.5. Child BMI-for-age percentile

Child BMI-for-age percentile was unrelated to predictor variables (ps>.19; Table 2).

3.2. Relationships Between Parent and Child Clinical Variables.

The relationships between parent and child clinical variables are displayed in Table 3. Child BMI-for-age percentile was correlated with child binge eating and overeating but was not related to parent clinical characteristics.

Table 3.

Descriptive Statistics and Relationships Between Parent and Child Clinieal Variables.

Mean St. Dev Parent OBE Parent SUD Parent BMI Parent Impulsivity Parent Depression Child OBE Child OOE Child Purging
Parent OBE 2.14 5.11 –
Parent SUD 14.54 15.45 0.19** –
Parent BMI 27.73 6.95 0.28** 0.06 –
Parent Impulsivity 58.34 12.56 0.27** 0.24** 0.15** –
Parent Depression 5.92 6.37 0.37** 0.26** 0.29** 0.47** –
Child OBE 0.88 3.34 0.32** 0.30 ** 0.15** 0.16** 0.28** –
Child OOE 1.72 4.12 0.30** 0.19** 0.18** 0.15** 0.21** 0.63** –
Child Purging 0.17 1.21 0.19** 0.29** 0.06 0.08 0.25** 0.36** 0.20** –
Child BMI 63.52 33.62 0.03 0.09 0.10* −0.01 0.05 0.19** 0.14** 0.06
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Note. Descriptive statistics (raw variables) presented in columns 1 and 2; bivariate correlations presented in columns 3–8. St. Dev = standard deviation; OBE = objective binge episode; SUD = substance use disorder behaviors; ED = eating disorder behaviors (i.e., binge eating); BMI = body mass index. Child BMI is represented in BMI-for-age percentile.

**

Correlation is significant at 0.01 (2-tailed)

*

Correlation is significant at 0.05 (2-tailed).

4. Discussion

In past work, co-occurring substance use and eating disorders were associated with greater psychopathology in adults. Additionally, parent substance use and parent eating disorders have each been associated with child psychopathology. Our study filled an important gap in the literature by examining whether the severity of co-occurring substance use and eating disorder behaviors in parents was associated with greater child eating and weight problems. The severity of comorbid parent substance use and eating disorder behaviors was associated with greater binge eating and purging in their children. Parent substance use and/or eating disorder behaviors were not related to child BMI-for-age percentile.

Consistent with prior work (Hilbert et al., 2014; Lydecker & Grilo, 2016; Lydecker & Grilo, 2017; Watson et al., 2018), parental eating disorder behaviors were significantly associated with child binge eating and child overeating. However, unlike prior work (Cummings et al., 2020; Grucza et al., 2010; Hilbert et al., 2014), we did not find that parental substance use behaviors were related to child weight or overeating. This may be because prior studies have not examined the relative contributions of parental eating disorder and substance use behaviors alone and in combination to child clinical presentation. Future research, including longitudinal work, should examine the relationships between parental behaviors and child eating behaviors in greater detail.

Importantly, the present work finds that parents with greater substance use and eating disorder behaviors reported more frequent binge eating and purging in their children. Moreover, parent substance use and eating disorder behaviors were each significantly correlated with greater parental impulsivity and depression symptoms. Together, these findings suggest that comorbidity in parents is associated with parental severity of psychopathology (Bahji et al., 2019; Becker & Grilo, 2015; Boswell & Grilo, 2020; Claudat et al., 2020) and is also associated with increased severity of eating-disorder symptoms in their children. These findings offer an early suggestion that identifying parents who engage in substance use and eating disorder behaviors could help target pediatric eating-disorder prevention programs and interventions.

Child age did not moderate relationships between parental substance use and eating disorder behaviors and child binge eating or overeating. One possibility is that this reflects increasing prevalence of early-onset EDs, including in children ages 9–10 (Rozzell, Moon, Klimek, Brown, & Blashill, 2019). Future work should examine these processes in a sample that extends to adolescence and emerging adulthood. Further, work examining developmental aspects of child eating psychopathology and overeating, including developmental changes in eating behaviors, parental awareness of child eating, and child food choice autonomy, may help to clarify these relationships.

Interestingly, even when accounting for variance due to parents’ impulsivity and depressive symptoms, parental substance use and eating disorder behaviors were significantly associated with greater child eating psychopathology. There may be separate relationships between child eating psychopathology and parental depressive symptoms/impulsive behaviors that are distinct from parental substance use and eating disorder behaviors. Alternatively, these parental characteristics may be manifestations of underlying psychopathology, with greater comorbidity indicating greater impairment and child risk. Still another hypothesis could be that parent substance use and eating disorder behaviors are discrete behaviors that are harder to separate from parenting practices or harder to prevent children from observing than depressive symptoms or impulsive behaviors. This hypothesis is consistent with work suggesting that substance use and eating behaviors in parents are more proximally related to similar behaviors in their children than family environment overall (Kluck et al., 2014).

There are likely shared biological and environmental factors that influence clinical severity in parents and their children. For example, one biological factor that could influence child clinical severity is reward dysfunction, which has been shown in children of parents with SUD (Cummings et al., 2020; Stice & Yokum, 2014) and may be heritable (Bezdjian et al., 2011; Elam et al., 2016; Rapuano et al., 2017). Future work should examine underlying factors that may influence clinical severity in parents and their children, including neurobiological and genetic liability, shared food environments, sociocultural factors, psychosocial stress, and parent-child interactions. Disentangling shared and unique factors associated with child risk for eating psychopathology versus overweight may help to target interventions and clarify underlying processes. Future work should investigate whether epigenetic and parenting-related mechanisms might mediate or moderate these effects (Kluck et al., 2014; Watson et al., 2018).

These findings should be understood in the context of their limitations. Given the cross-sectional nature of these findings, it will be important to examine the longitudinal relationships between parental substance use and eating disorder behaviors and child clinical characteristics to determine whether parent substance use and eating disorder behaviors tend to precede child outcomes, as well as to investigate pathways through which these relations unfold. Our sample was predominantly White, well-educated, biological parents, and reported relatively high rates of substance use and eating disorder behaviors, so these results may not generalize to samples with different characteristics (Burnette et al., Under Review). Additionally, some included clinical variables had improved distributions but did not achieve normality even after log transformation (Table 3S). Thus, future work should prioritize replication of these findings in nationally-representative samples, treatment-seeking samples, and in-person samples. In future work, it will be important to include both child and parent-based interview-based assessments in the research design to reduce self-report bias, improve assessment of restrictive ED behaviors in parents, and address shared method variance (e.g., parents with psychopathology may over-report psychopathology in their children). Additional work using anthropometric measurement and behavioral assessment of child eating might help to clarify these results. While a strength of our study was the inclusion of fathers in the dataset, more research on fathers is warranted, as they remain understudied (Khandpur, Blaine, Fisher, & Davison, 2014). It will be important to examine if the same associations we found extend to other groups of parents and primary caregivers not well-represented in our sample. Finally, because prior work has found that some types of parental substance use may be more strongly related to child eating behavior (Cummings & Gearhardt, 2020; Cummings, Gearhardt, Miller, Hyde, & Lumeng, 2019; Cummings et al., 2020), future work should investigate substance-specific effects of parental substance use and eating disorder behaviors on child eating psychopathology.

Nonetheless, these results have notable clinical implications. Treatment and prevention efforts may benefit from focus on comprehensive family-based assessment and interventions. Incorporating assessment and screening of parent substance use and eating disorder behaviors in pediatric medical and psychological care settings may allow for identification of youth at risk for greater eating-related problems and improve access to treatment for parents struggling with these problems. Intervention efforts aimed at parents may benefit from including evidence-based strategies to prevent behavioral substitution (e.g., substituting eating for substance use and vice-versa), reduce impulsive behaviors (e.g., skills-training; Boswell et al., 2018), and teach parents how to reinforce healthful behaviors in their children (e.g., Lock, 2015). Future work should investigate whether early discussion of parental SUD and ED behaviors and related intervention can prevent child onset of eating disorder and substance use behaviors.

In sum, parents with greater co-occurring substance use and eating disorder behaviors report greater eating-disorder symptoms in their children. Clinicians working with families, and those seeking to prevent pediatric EDs, should consider assessing and addressing parents’ psychopathology to improve prevention and treatment efforts.

Supplementary Material

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Highlights.

  • Comorbid substance use and eating disorder behaviors in parents (SUDxED) are understudied.

  • Greater co-occurring parent substance use and eating disorder behaviors were associated with pediatric binge eating and purging.

  • Parents’ substance use and/or eating disorder behaviors were unrelated to child weight.

  • Identifying parents with dual SUDxED behaviors may help intervention for pediatric eating disorders.

Acknowledgments

Author Disclosures

Role of Funding Sources: This research was supported, in part, by National Institutes of Health grants K24 DK70052 (Dr. Grilo) and K23 DK115893 (Dr. Lydecker). This publication was made possible by CTSA Grant Number UL1 TR001863 from the National Center for Advancing Translational Science (NCATS), components of the National Institutes of Health (NIH), and NIH roadmap for Medical Research. Its contents are solely the responsibility of the authors and do not necessarily represent the official view of NIH. Funders played no role in the content of this paper.

Footnotes

Author Conflict of Interest Statement

Conflicts of Interest: The authors have no conflicts of interest relevant to this article to disclose.

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