The Parental Bonding Instrument in adolescent patients with anorexia nervosa Russell J D , Kopec-Schrader E, Rey JM, Beumont PJV. The Parental Bonding Instrument in adolescent patients with anorexia nervosa. Acta Psychiatr Scand 1992: 86: 236-239.
The Parental Bonding Instrument (PSI) was administered to 54 adolescent patients with anorexia nervosa. Scores were compared with those of matched groups of normal and of nonanorectic adolescents referred for assessment to an adolescent psychiatric unit. Significant differences between the 3 groups were demonstrated with respect to care and protection dimensions. Overall scores of subjects in the anorectic group resembled those of normals rather than those of referred patients. Anorexia nervosa patients described their fathers and mothers as being more caring and their mothers as being less overprotective than did psychiatrically referred peers. The study raised questions concerning the use of the PBI in adolescents, in particular those with anorexia nervosa, and the role of the family in the aetiogenesis of this condition.
Adolescents with anorexia nervosa not infrequently complain that their parents are overprotective. This is consistent with assertions (1) concerning the “psychosomatic family” and the aetiology of anorexia nervosa. The families of these patients are often described as being rigid, overenmeshed, overprotective and inclined to detour conflict into the child’s illness. Anorexia nervosa might be seen to represent an effort to achieve a more age-appropriate level of autonomy in this situation, which then becomes selfperpetuating with the progression of the illness. Parents of patients with anorexia nervosa have been noted to be older as a group than those of their peers and have been described as conforming to certain stereotypes, the most prominent being that the mothers are overbearing and dominant and the fathers ineffectual. However, the evidence for these observations is largely anecdotal (2, 3). Garfinkel et al. (3) examined a number of hypotheses pertaining to the family in anorexia nervosa and identified difficulties with changes, family tasks and roles, communications and expression of affect. Whether this represented cause or effect of the illness was unclear but these findings would lend indirect support to the assertion of Minuchin et al. (1). The present study uses a standardized instrument to examine the reported perceptions of parenting in adolescent patients receiving treatment for anorexia nervosa. In particular, the aim was to ascertain whether these patients rated their parents as being overprotective.
236
’*’,
J. D. Russell E. Kopec-Schrader 1,3, J. M. Reylr3, P. J. V. B e ~ m o n t ’ * ~
’
Department of Psychiatry, University of Sydney, Formerly of Mt St Margaret Private Hospital Ryde, NSW and now Northside Clinic, Greenwich, NSW, Rivendell Adolescent Unit, Royal Prince Alfred Hospital, NSW, Lynton Private Hospital, Chatswood, NSW, Australia
Key words: anorexia nervosa; adolescence; parental bonding
Dr J Russell, Room 8 Clinical Sciences Building, Repatriation General Hospital, Hospital Road Concord, 1239 NSW, Australia Accepted for publication April 12, 1992
Material and methods Subjects
The anorexia group consisted of 54 adolescents receiving inpatient or outpatient treatment for anorexia nervosa. They were at different stages of their illness, ranging from first diagnosis through inpatient treatment, weight restoration and maintenance to outpatient follow-up, recovery and relapse. Inpatients were drawn from 4 different settings, 2 public hospitals (eating disorder programmes within general psychiatry wards) and 2 private hospitals with separate eating disorder units. Outpatients were in treatment with a psychiatrist whom they saw with varying frequency (i.e. from second weekly to third monthly). They were also seeing a nutritionist with varying frequency and some were attending groups for discharged patients. One was regularly seeing a paediatrician. All patients had at some stage met DSM-111-R criteria (4) for anorexia nervosa and all but two were living with their families. One girl (before her admission to hospital) and the only male outpatient were at boarding school. Ratings of socioeconomic status (SES) were based on the father’s occupation. Two types of controls, matched case for case by age, sex and SES, with the index group, were used: a clinically referred and a nonclinical group. The clinical group consisted of adolescents referred for treatment to a specialized adolescent facility (Riv-
PBI in anorexia nervosa endell Adolescent Unit, Sydney, Australia). This sample was unselected with regard to psychiatric diagnosis but patients suffering from an eating disorder were excluded. The commonest diagnoses were school refusal, depression (major and minor) and conduct disorders. The normal sample was drawn from a pool of adolescents attending 3 schools in the same area.
Results
The characteristics of the sample and the mean care and overprotection scores for mothers and fathers in each of the 3 groups are presented in Table 1. Higher PBI scores represent higher levels of care or overprotection. The main findings (Table 1) were that: 0 Anorexia nervosa patients reported both their mothers and fathers to be more caring and less overprotective than did nonanorectic referred patients. 0 Anorexia nervosa patients rated their mothers and fathers similarly to the nonclinical subjects for care and overprotection scales. Parker (6) suggests the concurrent use of care and overprotection scales to define 4 quadrants representative of 4 broad parenting styles: high care - low overprotection (optimal parenting), high care - high overprotection (affectionate constraint), low care high overprotection (affectionless control), and low care - low overprotection (neglectful parenting). The quadrants were obtained by intersecting both scales at their means using normative data. The normative data used here are those reported by Cubis et al. (7). Quadrant distributions are shown in Table 2. Overall differences were demonstrated in total maternal (1’ = 20.0) and paternal scores (x’ = 16.5) between normal controls, anorexia nervosa patients and adolescents referred to a psychiatric treatment facility ( 3 x 4 table: Bonferroni-corrected P-value being < 0.0125). 0 With respect to maternal quadrants (Table 2), anorexia nervosa patients reported their mothers as being high on care and low on overprotection (i.e. the optimum) more often than did referred patients (2 x 4 table: x2 = 17, P = 0.001) (Table 2). 0 With respect to paternal quadrants, anorexia nervosa patients reported their fathers as being high on care and low on overprotection (i.e. the opti-
Instrument
The Parental Bonding Instrument (PBI) originally described by Parker et al. in 1979 ( 5 ) was used. This is a 25-item self-rating instrument employing a 4point Likert-type scale, each item scoring 0-3. It contains statements concerning parental behaviours and attitudes, such as “spoke to me in a warm and friendly voice”, “did not want me to grow up”, to be judged by the respondent as more or less applicable to the parent in question. Separate forms have been completed for each parent. Two main bipolar constructs have been elucidated by factor analysis: care and overprotection. The first comprises items with content of affection and closeness at one extreme and indifference and rejection at the other. The second includes items suggestive of intrusiveness and control at one pole and encouragement of autonomy at the other. Statistical analysis
Comparisons of three groups were made - anorexia nervosa, normal subjects and psychiatric referrals using analysis of variance (ANOVA) and chi-square. Comparison of two groups (anorexia nervosa vs normals and anorexia nervosa vs psychiatric referrals) were made using Student’s t-test with Bonferroni correction of P-values and the chi-square test. The latter was also used to compare quadrant distributions.
Table 1. Demographic dataheans (SD) of parental care and overprotection in three groups ANOVA
Sex (% female) Mean age (years) Range Socioeconomic status Maternal care Maternal protection Paternal care Paternal protection
Anorexia nervosa (n=54)
Referred sample (n=54)
Normal sample (n=54)
95 15.4 12-19 3.5 (2.1)
95 15.4 12-19 3.6 (2.6)
95 15.2 12-19 4.0 (2.0)
28.5 (8.0) 11.8 (7) 24.5 (6.9) 10.3 (6.6)
22.1 (7.9) 16.2 (8.6) 19.4[7.6) 14.6 (7.5)
28.0 (6.2) 13.2 (7.3) 25.4 (8.6) 13.4 (7.7)
Significance level; * Pt0.05; ** P
The Parental Bonding Instrument (PSI) was administered to 54 adolescent patients with anorexia nervosa. Scores were compared with those of matched groups of normal and of nonanorectic adolescents referred for assessment to an adolescent psychiatric unit. Significant differences between the 3 groups were demonstrated with respect to care and protection dimensions. Overall scores of subjects in the anorectic group resembled those of normals rather than those of referred patients. Anorexia nervosa patients described their fathers and mothers as being more caring and their mothers as being less overprotective than did psychiatrically referred peers. The study raised questions concerning the use of the PBI in adolescents, in particular those with anorexia nervosa, and the role of the family in the aetiogenesis of this condition.
Adolescents with anorexia nervosa not infrequently complain that their parents are overprotective. This is consistent with assertions (1) concerning the “psychosomatic family” and the aetiology of anorexia nervosa. The families of these patients are often described as being rigid, overenmeshed, overprotective and inclined to detour conflict into the child’s illness. Anorexia nervosa might be seen to represent an effort to achieve a more age-appropriate level of autonomy in this situation, which then becomes selfperpetuating with the progression of the illness. Parents of patients with anorexia nervosa have been noted to be older as a group than those of their peers and have been described as conforming to certain stereotypes, the most prominent being that the mothers are overbearing and dominant and the fathers ineffectual. However, the evidence for these observations is largely anecdotal (2, 3). Garfinkel et al. (3) examined a number of hypotheses pertaining to the family in anorexia nervosa and identified difficulties with changes, family tasks and roles, communications and expression of affect. Whether this represented cause or effect of the illness was unclear but these findings would lend indirect support to the assertion of Minuchin et al. (1). The present study uses a standardized instrument to examine the reported perceptions of parenting in adolescent patients receiving treatment for anorexia nervosa. In particular, the aim was to ascertain whether these patients rated their parents as being overprotective.
236
’*’,
J. D. Russell E. Kopec-Schrader 1,3, J. M. Reylr3, P. J. V. B e ~ m o n t ’ * ~
’
Department of Psychiatry, University of Sydney, Formerly of Mt St Margaret Private Hospital Ryde, NSW and now Northside Clinic, Greenwich, NSW, Rivendell Adolescent Unit, Royal Prince Alfred Hospital, NSW, Lynton Private Hospital, Chatswood, NSW, Australia
Key words: anorexia nervosa; adolescence; parental bonding
Dr J Russell, Room 8 Clinical Sciences Building, Repatriation General Hospital, Hospital Road Concord, 1239 NSW, Australia Accepted for publication April 12, 1992
Material and methods Subjects
The anorexia group consisted of 54 adolescents receiving inpatient or outpatient treatment for anorexia nervosa. They were at different stages of their illness, ranging from first diagnosis through inpatient treatment, weight restoration and maintenance to outpatient follow-up, recovery and relapse. Inpatients were drawn from 4 different settings, 2 public hospitals (eating disorder programmes within general psychiatry wards) and 2 private hospitals with separate eating disorder units. Outpatients were in treatment with a psychiatrist whom they saw with varying frequency (i.e. from second weekly to third monthly). They were also seeing a nutritionist with varying frequency and some were attending groups for discharged patients. One was regularly seeing a paediatrician. All patients had at some stage met DSM-111-R criteria (4) for anorexia nervosa and all but two were living with their families. One girl (before her admission to hospital) and the only male outpatient were at boarding school. Ratings of socioeconomic status (SES) were based on the father’s occupation. Two types of controls, matched case for case by age, sex and SES, with the index group, were used: a clinically referred and a nonclinical group. The clinical group consisted of adolescents referred for treatment to a specialized adolescent facility (Riv-
PBI in anorexia nervosa endell Adolescent Unit, Sydney, Australia). This sample was unselected with regard to psychiatric diagnosis but patients suffering from an eating disorder were excluded. The commonest diagnoses were school refusal, depression (major and minor) and conduct disorders. The normal sample was drawn from a pool of adolescents attending 3 schools in the same area.
Results
The characteristics of the sample and the mean care and overprotection scores for mothers and fathers in each of the 3 groups are presented in Table 1. Higher PBI scores represent higher levels of care or overprotection. The main findings (Table 1) were that: 0 Anorexia nervosa patients reported both their mothers and fathers to be more caring and less overprotective than did nonanorectic referred patients. 0 Anorexia nervosa patients rated their mothers and fathers similarly to the nonclinical subjects for care and overprotection scales. Parker (6) suggests the concurrent use of care and overprotection scales to define 4 quadrants representative of 4 broad parenting styles: high care - low overprotection (optimal parenting), high care - high overprotection (affectionate constraint), low care high overprotection (affectionless control), and low care - low overprotection (neglectful parenting). The quadrants were obtained by intersecting both scales at their means using normative data. The normative data used here are those reported by Cubis et al. (7). Quadrant distributions are shown in Table 2. Overall differences were demonstrated in total maternal (1’ = 20.0) and paternal scores (x’ = 16.5) between normal controls, anorexia nervosa patients and adolescents referred to a psychiatric treatment facility ( 3 x 4 table: Bonferroni-corrected P-value being < 0.0125). 0 With respect to maternal quadrants (Table 2), anorexia nervosa patients reported their mothers as being high on care and low on overprotection (i.e. the optimum) more often than did referred patients (2 x 4 table: x2 = 17, P = 0.001) (Table 2). 0 With respect to paternal quadrants, anorexia nervosa patients reported their fathers as being high on care and low on overprotection (i.e. the opti-
Instrument
The Parental Bonding Instrument (PBI) originally described by Parker et al. in 1979 ( 5 ) was used. This is a 25-item self-rating instrument employing a 4point Likert-type scale, each item scoring 0-3. It contains statements concerning parental behaviours and attitudes, such as “spoke to me in a warm and friendly voice”, “did not want me to grow up”, to be judged by the respondent as more or less applicable to the parent in question. Separate forms have been completed for each parent. Two main bipolar constructs have been elucidated by factor analysis: care and overprotection. The first comprises items with content of affection and closeness at one extreme and indifference and rejection at the other. The second includes items suggestive of intrusiveness and control at one pole and encouragement of autonomy at the other. Statistical analysis
Comparisons of three groups were made - anorexia nervosa, normal subjects and psychiatric referrals using analysis of variance (ANOVA) and chi-square. Comparison of two groups (anorexia nervosa vs normals and anorexia nervosa vs psychiatric referrals) were made using Student’s t-test with Bonferroni correction of P-values and the chi-square test. The latter was also used to compare quadrant distributions.
Table 1. Demographic dataheans (SD) of parental care and overprotection in three groups ANOVA
Sex (% female) Mean age (years) Range Socioeconomic status Maternal care Maternal protection Paternal care Paternal protection
Anorexia nervosa (n=54)
Referred sample (n=54)
Normal sample (n=54)
95 15.4 12-19 3.5 (2.1)
95 15.4 12-19 3.6 (2.6)
95 15.2 12-19 4.0 (2.0)
28.5 (8.0) 11.8 (7) 24.5 (6.9) 10.3 (6.6)
22.1 (7.9) 16.2 (8.6) 19.4[7.6) 14.6 (7.5)
28.0 (6.2) 13.2 (7.3) 25.4 (8.6) 13.4 (7.7)
Significance level; * Pt0.05; ** P
