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This article systematically reviewed studies of parental bonding in people with eating disorders. MEDLINE, PsychINFO, EMBASE and CINAHL were searched to identify studies that compared parental bonding in people diagnosed with an eating disorder relative to non-clinical controls. Twenty-four studies were identified. Women with eating disorders typically reported lower parental care and higher parental protection compared to non-clinical, but not psychiatric, controls. Interestingly, a modest number of studies found that these relationships were mediated by avoidant problem solving style and several schemas from the Young Schema Questionnaire (YSQ; Schmidt, Joiner, Young, & Telch, 1995). While there are methodological limitations associated with the reviewed studies, they do offer some support for the proposal that difficulties in parent–child relationships predispose women to eating disorders and other psychiatric diagnoses.

There are a number of theoretical accounts of the development of eating disorders. The most influential of these for psychological therapy arise from the cognitive behavioural tradition (Fairburn & Harrison, 2003). This theoretical approach assumes that dysfunctional beliefs underlie psychological distress and most crucially that these beliefs arise from negative early life experiences (Beck, Rush, Shaw, & Emery, 1979). Consistent with this theme, a recent cognitive model of eating disorders suggests that dysfunctional self-loathing beliefs are key to the development of eating disorders and arise from negative childhood experiences, such as parental neglect or indifference (Cooper, Wells, & Todd, 2004). Cognitive behavioural theories are not the only theoretical contributions suggesting that difficult relationships between parents and children could be implicated in the onset of eating disorders. Using attachment theory (Bowlby, 1969) as an explanatory framework, it has been suggested that insecure attachments to caregivers are common in those with eating disorders. The symptoms of their eating disorder are assumed to represent an attempt to maintain physical and psychological proximity to a caregiver (O'kearney, 1996 and Zachrisson and Skarderud, 2010). Likewise, psychodynamic theories suggest that parents of those who develop eating disorders are demanding/over-controlling and emotionally unresponsive. This is assumed to result in either; 1) a need for the adolescent to remain child-like to avoid abandonment, 2) a refusal to eat to subdue the internalised controlling parent, or 3) weight-control behaviours to maintain closeness to the parent (Sugarman and Kurash, 1982 and Swift and Stern, 1982). It is important to assess the empirical support for the hypothesised link between early parent–child relationships and eating disorders. To date, four systematic literature reviews have sought to synthesise data on this empirical question (O'kearney, 1996, O'Shaughnessy and Dallos, 2009, Ward et al., 2000 and Zachrisson and Skarderud, 2010). Before considering their conclusions, it is important to note that they conceptualise existing empirical studies as either considering the “attachment construct” as defined by Bowlby (1969) or considering “parental bonding” as defined by Parker, Tupling, and Brown (1979). Briefly, the “attachment construct” referred to in these reviews is defined by Bowlby's attachment theory (Bowlby, 1969). This suggests that children respond to caregiver's behaviour in ways that most effectively achieve care and security. If attachment figures are experienced as unresponsive, frightening, or neglectful, children are assumed to develop one of three insecure attachment styles that continue across the lifespan, namely avoidant, preoccupied, or disorganised. Avoidant attachment is associated with withdrawal and an avoidance of emotional intimacy; preoccupied attachment is associated with attempts to avoid rejection and extreme distress on separation from others; and finally, disorganised attachment is characterised by a combination of seeking care and avoiding it and dissociating from the environment in the face of this dilemma. Parental bonding, in contrast to the attachment construct, has been defined by Parker et al. (1979) as the parental contribution to parent–child relationships and is typically assessed using the Parental Bonding Instrument (PBI) (Parker et al., 1979). Parker et al. (1979) define maternal and paternal contribution to bonding along two dimensions, namely care and protection. The dimension of care ranges from affection, emotional warmth, empathy, and closeness, to emotional coldness, indifference and neglect. The dimension of overprotection/control ranges from control, overprotection, intrusion, infantilisation, and prevention of independent behaviour, to allowance of independence and autonomy. Parker et al. (1979) suggest that this parental contribution to the parent–child bonding is an area that is neglected, or at best only briefly considered in attachment theory. This indeed appears to be the case given that consideration of parental behaviour in attachment theory revolves around the emotional responsiveness to the child and fails to consider the effects of parental protection/control. Two of the reviews addressing parent–child relationships in people with eating disorders have included studies assessing both Bowlby's attachment construct and parental bonding as defined by Parker et al. (1979). The initial review concluded that, compared to non-clinical controls, those with eating disorders remember both parents as less caring, but only their father as more protective — with this latter finding more common in women with Bulimia Nervosa (BN) (O'kearney, 1996). By contrast, an updated review found that clients with eating disorders consistently remember their parents as more controlling and less affectionate than their non-clinical counterparts (so called affectionless control) (Ward et al., 2000). Both reviews also find that those with eating disorders encounter separation anxiety and are more likely than controls to be insecurely attached. The most recent of these reviews also found that women with Anorexia Nervosa (AN) tend to have an avoidant attachment style while women with BN tend to be preoccupied in their attachment style (Ward et al., 2000). This latter finding has also been supported in more recent reviews of attachment in those with eating disorders (O'Shaughnessy and Dallos, 2009 and Zachrisson and Skarderud, 2010). In the most recent reviews in this area (O'Shaughnessy and Dallos, 2009 and Zachrisson and Skarderud, 2010), the authors have chosen to focus solely on the studies assessing the Bowlbian attachment construct, thereby excluding the studies assessing parental bonding. The present article reviewed empirical studies assessing parental bonding in those with eating disorders, updating the previous review conducted in 1999 by Ward et al. (2000). An updated review is crucial for three reasons. First, only 11 studies were reviewed up to 1999 and many more have been undertaken since. Second, while the authors of the review noted a predominance of “affectionless control” parenting in people with eating disorders, careful inspection of the reviewed studies reveals contradictory findings. Third, both previous reviews in this area (O'kearney, 1996 and Ward et al., 2000) highlighted limitations of the studies they reviewed. In particular, the studies did not incorporate a psychiatric control group, failed to select healthy controls in such a way to limit the confounding aspects of disordered eating behaviours, and did not consider how parental bonding might result in the manifestation of eating disorders. This review aimed to update these previous reviews. The aims were to: (1) identify the extent to which parental bonding, as defined by Parker et al. (1979), is found to differ for people with eating disorders relative to non-clinical samples in the studies published since 1999; (2) assess the methodological quality of this research and identify what further research is required; and (3) identify any mediators of the relationship between parental bonding and eating disorders. This will serve to extend our understanding of the potential developmental pathways of disordered eating behaviours.