A paper on mothers with eating disorders and their children emotional functioning. A study on paternal role

1. SPECIAL ISSUE
A Six-year Prospective Study on Children of Mothers with Eating
Disorders: The Role of Paternal Psychological Profiles
Silvia Cimino1*, Luca Cerniglia2, Marinella Paciello2 & Stefania Sinesi1
1Department of Dynamic and Clinical Psychology, Faculty of Medicine and Psychology, Sapienza University of Rome, Rome
2Uninettuno Telematic International University, Rome
Abstract
Background: Several studies have suggested that maternal eating disorders (EDs) represent a significant risk factor for children’s affective
and behavioral development. Yet, little emphasis has been placed on the paternal role.
Objectives: The present longitudinal study aimed to clarify the role of maternal EDs and the influence of paternal psychological profiles
on children’s emotional development.
Method: Our sample was composed of N= 64 families with firstborn children selected through preschools, primary schools, and outpatient
clinics in central Italy. Parents and children participated in a 6-year longitudinal protocol that included a diagnostic interview conducted by
clinicians (Structured Clinical Interview for DSM-IV Axis I Disorders [SCID-I]), a self-report (Symptom Checklist-90-Revised [SCL-90-R]),
and a parental report-form questionnaire (Child Behavior Checklist [CBCL]).
Results: The influence of mothers’ EDs on their children’s emotional development was confirmed. Moreover, fathers’ anxiety and
obsessive-compulsive problems in association with mothers’ EDs and depressive symptoms influenced the onset of both internalizing
and externalizing difficulties in their children over time.
Conclusion: Our results suggest that fathers’ psychopathological risk affects the development of emotional problems in children with
mothers who have EDs. Copyright © 2012 John Wiley & Sons, Ltd and Eating Disorders Association.
Keywords
maternal eating disorders; paternal psychopathological risk; longitudinal study
*Correspondence
Silvia Cimino, Department of Dynamic and Clinical Psychology, Faculty of Medicine and Psychology, Sapienza University of Rome, Via dei Marsi n. 78, 00185 Rome.
Tel: +39 338-3080680; Fax: +39 06 97997735.
Email: silcimin@tin.it; silvia.cimino@uniroma1.it
Published online in Wiley Online Library (wileyonlinelibrary.com) DOI: 10.1002/erv.2218
Introduction and aims
The international scientific literature points to maternal psycho-pathology
as a crucial risk factor for the development and mainte-nance
of emotional and behavioral problems in children (Cox &
Barton, 2010). In particular, studies have focused on the influence
of maternal depression on internalizing problems in children and,
more recently, on the impact of maternal eating disorders (EDs)
on children’s mental health (Bagner, Pettit, Lewinsohn, & Seeley,
2010; Watkins, Cooper, & Lask, 2012).
Various studies have examined food refusal behaviors and
weight faltering in children of mothers with EDs. The resultant
empirical and clinical research findings have led many authors
to suggest that children’s feeding disorders are associated with
mothers’ EDs. Notably, compared to children of women without
an ED, children of women suffering from EDs have been reported
to show a three-fold increase in the risk of manifesting feeding
problems in the first years of life (Micali, Simonoff, Stahl, &
Treasure, 2011). Furthermore, the presence of EDs in mothers
may predict infants’ poor physical growth and an early onset of
feeding disorders (Ammaniti, Lucarelli, Cimino, D’Olimpio, &
Chatoor, 2012).
A limited number of studies have examined whether maternal
EDs affect children’s emotional development. An association
was found between mothers EDs and negative outcomes on the
emotional functioning in their children (e.g. aggressive and oppo-sitional
behaviors). Empirical and clinical studies point out that
the children of women suffering from EDs show a higher risk of
manifesting maladaptive emotional and behavioral functioning
in their first years of life if compared to healthy controls (Whelan
& Cooper, 2000) Moreover, mothers with EDs have been shown
to be more likely to have hard to handle, irritable, and unfriendly
children, suggesting that the presence of maternal EDs may
impede the building of adaptive interactional exchanges in care-giving
contexts (Zerwas et al., 2012).
While most studies in this field have dealt preeminently with
maternal EDs and their influence on children, fathers’ psycholog-ical
profiles, which may represent a significant risk and/or protec-tive
factor, have received relatively little attention. The limited
research examining paternal psychopathology thus far has sug-gested
that it may play a crucial role in the quality of caregiving,
modulating and integrating with interactional mother-infant
patterns. In particular, a father with psychopathologic symptoms
that shows a low level of responsiveness to his children may be
Eur. Eat. Disorders Rev. (2012)© 2012 John Wiley & Sons, Ltd and Eating Disorders Association.

2. Mothers with Eating Disorders S. Cimino et al.
a risk factor for the onset of children’s maladaptive behavior
(Elgar, Mills, & McGrath, 2007). Indeed, it has been proposed
that a combination of maternal and paternal psychopathologies
may create a style of co-parenting dominated by negative interac-tive
cycles with the children (Pinquart & Teubert, 2010). Interest-ingly,
Fassino, Amianto, and Abbate-Daga (2009) suggested that
this association between parents’ psychopathological symptoms
and children’s EDs may remain stable over time. On the other
hand, adaptive paternal psychological functioning could facilitate
mothers’ understanding of their children’s needs and thereby may
serve as a protective factor against the development of psycho-pathologies
in children (Cooper, Whelan, Woolgar, Morrell, &
Murray, 2004). However, there is a dearth of information in the
scientific literature related to the father’s role as a potential risk
or protective factor.
Based on the above theoretical foundations, the present longi-tudinal
study aimed to further elaborate on the impact maternal
EDs on children’s emotional functioning from infancy through
early childhood, including a close examination of the influence
of paternal psychological profiles. Our study had the following
three specific objectives:
1. To evaluate mothers’ and fathers’ psychological profiles longi-tudinally
in a sample of families with women who have EDs
and in a control group;
2. To evaluate the children’s emotional/adaptive profiles in the
clinical and non-clinical samples over time;
3. To elucidate the role of maternal EDs, the effect of maternal
psychological profiles, and the influence of paternal psycho-logical
profiles on children’s emotional development.
Methodology
Study design and sample
A 6-year longitudinal study was conducted with three serial
assessments. The initial assessment (T1) was administered face-to-
face over a period of one year by a group of trained psychologists
who visited the families in their homes. The second assessment (T2)
was administered 3 years after T1, and the third assessment (T3) was
administered 3 years after T2. During the T1 assessment, we admin-istered
all sections of the Structured Clinical Interview for DSM-IV
Axis I Disorders (SCID-I, non-patient version) to the mothers
(First, Spitzer, Gibbon, & Williams, 1997).
A total of 297 families were recruited from preschools, primary
schools, and outpatient clinics in central Italy. The study sample
was divided into two subgroups: families in which the mothers
suffered from an ED (with no Axis I comorbidity) constituted
the clinical group (CG; N= 35); and families in which the
mothers received no diagnosis constituted the non-clinical group
(NCG; N= 201). Families in which the mothers received a diag-nosis
other than ED were excluded at T1 (dysthymic disorder,
N= 15; substance dependence, N= 3; social phobia, N= 5; Axis
I comorbidity, N= 7). An additional N= 13 families were elimi-nated
because they were pursuing a psychological treatment,
and we wanted to avoid the potential influence of psychothera-peutic
or pharmacological intervention on family dynamics. And
N= 18 families were later excluded from the analysis due to missing
data in the interviews.
Consistent with prior prospective studies (Lane, 2008), the
drop-off rate at the second assessment (T2) 3 years after T1, and
the third assessment (T3), 3 years after T2, were ~53% and
~62%, respectively. Thus, at T2, we assessed 111 families
(N = 31 in CG; N= 80 in NCG) and at T3 we assessed 90 families
(N = 31 in CG; N= 59 in NCG). Follow-up data were available for
89% of the CG subjects at T2 and T3 and for 40% of NCG
subjects at T2 and 29.5% of NCG subjects at T3.
The CG subjects were paired with NCG subjects by age of the
children, age of the mothers, and the families’ socio-economic
status. The sample presented for this study therefore included
N= 64 families with firstborn children (N = 31 in CG; N= 33 in
NCG). In the CG, about half of the mothers (16/31) suffered from
anorexia nervosa and about half (15/31) suffered from bulimia
nervosa. Most of these mothers (87%) had a documented clinical
history of their EDs with a diagnosis in their early adulthood using
the SCID-I (non-patient version). These diagnoses were confirmed
at T1 in our study.
Demographic data
In both the CG and NCG, all parents were Caucasian and most
(87%) were of middle socio-economic status (SES; Hollingshead,
1975). A majority (68%) of the parents lived together; 89% of the
fathers and 71% of the mothers were employed; 82% of the
children went to preschool or kindergarten. Most (86%) of the
children had been breast-fed. All the partners of the mothers
recruited for the study were the biological fathers of the children.
At T1, the mean age of the mothers was 33.2 years (standard
deviation [sd]= 3.1) and the mean age of the fathers was 35.3 years
(sd= 2.5). The children in both groups were 50% males and
50% females. The children had a mean age of 2.4 years (sd= 0.4)
at T1, 5.3 years (sd= 0.5) at T2, and 7.6 years (sd = 0.4) at T3.
Tools and procedures
All parents signed an informed consent for all the procedures. The
mothers and the fathers each completed the Symptom Checklist-
90-Revised (SCL-90-R) and the Child Behavior Checklist (CBCL),
described below, at T1, T2 and T3 independently.
The SCL-90-R is a 90-item self-report symptom inventory aimed
to measure psychological symptoms and psychological distress
(Derogatis, 1994). Its main symptom dimensions are Somatization,
Obsessive-Compulsivity, Interpersonal Sensitivity, Depression, Anxiety,
Hostility, Phobic Anxiety, Paranoid Ideation, and Psychoticism. The
SCL-90-R has been shown previously to have good internal coher-ence
(a = 0.70–0.96) in adolescents and adults (Italian validated
version - Prunas, Sarno, Preti, Madeddu, & Perugini, 2011).
The CBCL is a questionnaire filled out by parents and caregivers
to assess a child’s abilities and his/her specific behavioral/emotional
characteristics. The CBCL/1½–5 (Achenbach & Rescorla, 2001) is
composed of 100 items. Its Internalizing Problems Scale consists of
four subscales: Emotionally Reactive, Anxious/Depressed, Somatic
Complaints, and Withdrawn. And its Externalizing Problems Scale is
composed of two subscales: Attention Problems and Aggressive
Behavior. The CBCL/1½–5 has high test-retest reliability and high
internal consistency (Achenbach & Rescorla, 2001). The CBCL/
6–18 (Achenbach & Rescorla, 2001) is composed of 113 items. Its
Internalizing Problems Scale consists of three subscales: Anxious/
Depressed, Withdrawn/Depressed, and Somatic Complaints. And its
Eur. Eat. Disorders Rev. (2012)© 2012 John Wiley & Sons, Ltd and Eating Disorders Association.

3. S. Cimino et al. Mothers with Eating Disorders
Externalizing Problems Scale consists of two subscales: Rule-Breaking
Behavior and Aggressive Behavior. The criterion-related validity of
both versions of the CBCL is supported by the ability of the CBCL’s
quantitative scale scores to discriminate between demographically
matched, referred and non-referred children (Kim et al., 2012). In
the present study, we used the Italian validated versions and the
Italian cut-off values (Frigerio & Montirosso, 2002).
Statistical analysis
As a preliminary step, the normality of variables was determined
and intra-group correlations were assessed to control for the inde-pendency
of the relationships between mothers’ and fathers’
dimensions in the GC and NCG. Descriptive analyses demon-strated
that all variables were normally distributed. Correlational
analyses showed that, in both groups, the relations between
mothers’ and fathers’ SCL-90-R dimensions were not significantly
or slightly related (<.30) whereas the mothers’ and fathers’ CBCL
evaluations correlated significantly and strongly (>.30). Thus, for
comparison of SCL-90-R dimensions, we considered the mothers’
and fathers’ scores within each group to be independent, whereas
for the children’s dimensions, we aggregated the mothers’ and
fathers’ CBCL dimensions as mean scores for each child.
We began our analyses by examining fluctuations over time in
parental dimensions of SCL-90-R, separately for each group.
Specifically, we examined mean scores from Time 1 to Time 3
on each SCL-90-R parental dimension by performing repeated
measure analyses of variance, using Time as a within-subject
factor and Group as a between subject factor. Then, analyses of
variance (ANOVA) were used to test significant differences
between CG and NCG on parental SCL-90-R dimensions and
CBCL dimensions, separately for each time of assessment. Finally,
a series of regression analyses were conducted to examine the in-fluence
of specific SCL-90-R dimensions related to eating disorder
at Time 1 on three specific child’s specific emotional/adaptive
and, in general, on internalizing and externalizing outcomes from
Time 1 to Time 3. The specific SCL-90-R dimensions and child
outcomes were selected based on empirical literature (Ammaniti
et al., 2012; Frigerio & Montirosso, 2002). In all regression models
the belonging to clinical/non clinical group and gender were
entered at Step 1, the maternal dimensions at Time 1 were entered
at Step 2, the paternal dimensions at Time 1 were entered at Step 3,
the interaction between some specific mothers’ and fathers’
dimensions related to eating disorder were entered at Step 4.
All analyses were performed with SPSS software (version 15.0).
Results
Stability and change of parents’ psychological
SCL-90-R dimensions
As shown in Table 1, mothers in the CG had higher scores than
mothers in the NCG on all SCL90-R dimensions over time. Fathers
in the CG had higher scores than fathers in the NCG on all dimen-sions
at T1 and T3, but not at T2 (Table 2). At T2, fathers’ SCL-90-R
dimension scores differed significantly between the groups only on
the obsessive-compulsive, anxiety, and psychoticism subscales.
The mothers’ scores on SCL-90-R dimensions were all stable
over time. They showed one significant interaction between time
point and group on depression (F2,57 = 3.64; p<.05; Wilks
Lambda = .88). Means tended to increase over time for the CG,
but remained stable for the NCG. The fathers’ SCL-90-R results
indicated that interpersonal sensitivity and phobic anxiety were
stable over time, whereas obsessive-compulsive (F2,57 = 13.32;
p<.01; Wilks’ Lambda = .68), somatization (F2,57 = 4.93; p<.01;
Wilks’ Lambda = .88), hostility (F2,57 = 3.66; p<.05; Wilks’
Lambda= .88), anxiety (F2,57= 9.66; p<.01; Wilks’ Lambda= .75),
depression (F2,57 = 3.42; p<.05; Wilks’ Lambda= .89), paranoid
ideation (F2,57 = 3,10; p<.05; Wilks’ Lambda= .90], and psychoti-cism
(F2,57= 6.52; p<.01; Wilks’ Lambda= .81) changed signifi-cantly
over time. Mean scores followed a quadratic trend with
a decline from T1 to T2, and an increase from T2 to T3. There
were significant interactions between time point and group
on somatization (F2,57= 5.01; p<.01; Wilks’ Lambda = .85),
Table 1 Means (standard deviation) of mothers’ SCL-90-R subscales by group and evaluation time (1, 2 and 3)
TIME 1 TIME 2 TIME 3
CG NCG Fisher F Test Z2 CG NCG Fisher F Test Z2 CG NCG Fisher F Test Z2 CUT-OFF
SOM 1.31 (.82) .14 (.11) F (1,58) = 59.71*** .51 1.32 (.82) .14 (.09) F (1,58) = 59.67*** .51 1.43 (.88) .12 (.12) F (1,58) = 64.93*** .53 >1.03
O-C 1.19 (.80) .11 (.11) F (1,58) = 53.48*** .48 1.19 (.81) .10 (.10) F (1,58) = 53.63*** .48 1.17 (.78) .06 (.08) F (1,58) = 59.33*** .51 >1.03
I - S 1.08 (.60) .11 (.11) F (1,58) = 75.07*** .56 1.05 (.65) .10 (.10) F (1,58) = 62.67*** .52 1.17 (.46) .06 (.09) F (1,58) = 169.80*** .74 >0.91
DEP 1.47 (.51) .12 (.11) F (1,58) = 201.60*** .78 1.49 (.55) .11 (.11) F (1,58) = 182.98*** .72 1.61 (.53) .07 (.09) F (1,58) = 244.07*** .81 >1.11
ANX 1.28 (.83) .11 (.12) F (1,58) = 57.84*** .50 1.24 (.85) .08 (.10) F (1,58) = 54.66*** .48 1.25 (.75) .06 (.11) F (1,58) = 73.93*** .56 >0.91
HOS .97 (.66) .10 (.15) F (1,58) = 49.71*** .46 .89 (.65) .07 (.10) F (1,58) = 47.05*** .45 1.03 (.60) .08 (.12) F (1,58) = 70.61*** .55 >0.83
PHOB 1.09 (.82) .12 (.14) F (1,58) = 40.59*** .41 1.05 (.85) .11 (13) F (1,58) = 35.38*** .38 .94 (.72) .14 (.11) F (1,58) = 37.10*** .39 >0.58
PAR 1.11 (.75) .08 (.12) F (1,58) = 55.28*** .49 1.06 (.69) .07 (.11) F (1,58) = 58.92*** .50 1.18 (.58) .03 (.07) F (1,58) = 116.51*** .67 >0.91
PSY 1.07 (.82) .15 (.13) F (1,58) = 37.23*** .39 1.05 (.81) .12 (.12) F (1,58) = 38.37*** .40 1.22 (.81) .08 (.09) F (1,58) = 58.94*** .50 >0.42
Note.
***significant at p<.001;
**significant at p<.01;
*significant at p<.05
SOM: Somatization; O-C: Obsessive-Compulsive; I-S: Interpersonal Sensitivity; DEP: Depression; ANX: Anxiety; HOS: Hostility; PHOB: Phobic Anxiety; PAR: Paranoid
Ideation; PSY: Psychoticism. The last column reports cut-off scores in the referring population.
Eur. Eat. Disorders Rev. (2012)© 2012 John Wiley & Sons, Ltd and Eating Disorders Association.

4. Mothers with Eating Disorders S. Cimino et al.
Table 2 Means (standard deviation) of fathers’ SCL-90-R subscales by group and evaluation time (1, 2 and 3)
TIME 1 TIME 2 TIME 3
CG NCG Fisher F Test Z2 CG NCG Fisher F Test Z2 CG NCG Fisher F Test Z2 CUT-OFF
SOM 1.16 (.36) .44 (.49) F (1,58) = 41.64*** .42 .63 (.55) .43 (.43) F (1,58) = 2.53 .04 .99 (.46) .48 (.51) F (1,58) = 17.05*** .23 >1.03
O-C 2.64 (.79) .99 (1.38) F (1,58) = 32.05*** .36 1.37 (1.30) .41 (.44) F (1,58) = 14.49*** .20 2.23 (1.11) 1.11 (1.43) F (1,58) = 11.55*** .17 >1.03
I - S 1.24 (.49) .55 (.67) F (1,58) = 21.13*** .27 .81 (.74) .53 (.60) F (1,58) = 2.64 .04 1.21 (.65) .58 (.67) F (1,58) = 13.97*** .19 >0.91
DEP 1.07 (.33) .44 (.44) F (1,58) = 38.18*** .40 .66 (.49) .43 (.42) F (1,58) = 3.69 .06 .98 (.39) .47 (.45) F (1,58) = 13.97*** .27 >1.11
ANX 2.57 (.88) .99 (1.29) F (1,58) = 30.69*** .35 1.43 (1.38) .52 (.54) F (1,58) = 11.30*** .16 2.28 (1.11) 1.09 (1.32) F (1,58) = 14.36*** .20 >0.91
HOS 1.06 (.44) .44 (.42) F (1,58) = 30.41*** .34 .59 (.50) .46 (.46) F (1,58) = 1.14 .02 .86 (.49) .46 (.43) F (1,58) = 11.35*** .16 >0.83
PHOB 1.10 (.50) .47 (.50) F (1,58) = 24.11*** .29 .76 (.64) .52 (.52) F (1,58) = 2.51 .04 1.10 (.55) .49 (.49) F (1,58) = 21.30*** .27 >0.58
PAR 1.24 (.53) .43 (.52) F (1,58) = 35.98*** .38 .72 (.64) .46 (.49) F (1,58) = 3.02 .05 1.14 (.59) .46 (.52) F (1,58) = 22.96*** .28 >0.91
PSY 1.07 (.39) .50 (.48) F (1,58) = 24.65*** .30 .65 (.47) .40 (.29) F (1,58) = 6.05* .10 1.00 (.45) .54 (.49) F (1,58) = 14.75*** .20 >0.42
Note.
***significant at p<.001;
**significant at p<.01;
*significant at p<.05
SOM: Somatization; O-C: Obsessive-Compulsive; I-S: Interpersonal Sensitivity; DEP: Depression; ANX: Anxiety; HOS: Hostility; PHOB: Phobic Anxiety; PAR: Paranoid
Ideation; PSY: Psychoticism. The last column reports cut-off scores in the referring population.
depression (F2,57 = 3.02; p<.05; Wilks’ Lambda = .90), hostility
(F2,57 = 4.40; p<.01; Wilks’ Lambda= .86), paranoid ideation
(F2,57 = 3.93; p<.05; Wilks’ Lambda= .87). For these dimensions,
CG mean scores followed a quadratic trend, whereas NCG mean
scores remained stable and low. Nevertheless, in the CG, fathers’
scores on the obsessive-compulsive, anxiety, phobic anxiety, and
psychoticism subscales exceeded the cut-offs for the Italian popula-tion
at all three time points.
Children’s longitudinal profiles: differences
between the CG and the NCG
The emotional-adaptive profiles of children in the CG had signif-icantly
higher scores than those of children in the NCG on all
CBCL dimensions at all three assessment time points (Table 3).
Predictive power of maternal EDs and of mothers’
and fathers’ psychological profiles on children’s
specific emotional/adaptive outcomes
All regression model results showed that belonging to the CG
significantly predicted the child’s outcomes, explaining 22–82%
of the variance (Tables 4–9). In particular, mothers’ somatization
contributed significantly to explaining higher scores for children in
the aggressive behavior and externalizing problems subscales at all
assessment time points as well as in the withdrawal/depression
subscale at T3. The mothers’ psychoticism score was related to the
children’s anxiety/depression subscale scores at T1 and T2.
Meanwhile, obsessive-compulsive symptoms revealed in the fathers’
SCL-90-R subscales were related to children’s internalizing scores
at T1. Moreover, fathers’ anxiety subscale scores contributed
Table 3 Means (standard deviation) of child’s CBCL subscales by group and evaluation time (1, 2 and 3)
TIME 1 TIME 2 TIME 3
CG NCG Fisher F Test Z2 CG NCG Fisher F Test Z2 CG NCG Fisher F Test Z2 CUT-OFF
E-R 6.77 (2.68) 2.48 (1.77) F(1,58) = 53.36*** .45 7.67 (2.17) 2.65 (1.78) F(1,58) = 95.72*** .62 __ __ __ __ >7
A-D 5.08 (2.46) 2.93 (1.62) F(1,58) = 16.03*** .22 5.52 (1.95) 3.20 (1.65) F(1,58) = 24.70*** .30 10.98 (1.96) 3.85 (1.86) F(1,58) = 209,49*** .78 >8/>11
S-C 7.12 (2.72) 2.97 (1.70) F(1,58) = 50.23*** .46 8.32 (2.12) 3.37 (1.47) F(1,58) = 110.62*** .66 7.23 (2.17) 3.90 (1.38) F(1,58) = 50,46*** .46 >6/>5
WIT 5.90 (2.08) 2.08 (1.02) F(1,58) = 81.37*** .58 6.62 (1.39) 2.58 (1.33) F(1,58) = 131.80*** .69 6.97 (1.98) 2.17 (.95) F(1,58) = 143,04*** .71 >4/>6
A-P 4.63 (1.18) 2.40 (1.03) F(1,58) = 60.97*** .51 5.07 (1.02) 2.67 (1.20) F(1,58) = 69.57*** .54 7.22 (1.76) 2.67 (1.15) F(1,58) = 140,16*** .71 >7/>11
A-B 19.77 (5.65) 8.72 (5.45) F(1,58) = 59.37*** .51 21.10 (5.07) 9.52 (6.18) F(1,58) = 62.93*** .52 12.95 (3.55) 6.67 (1.80) F(1,58) = 74,86*** .56 >6/>18
R-B __ __ __ __ __ __ __ __ 11.05 (2.90) 4.67 (1.94) F(1,58) = 100,47*** .63 >4
T-P __ __ __ __ __ __ __ __ 10.10 (2.25) 4.18 (1.80) F(1,58) = 126,40*** .68 >2
S-P __ __ __ __ __ __ __ __ 7.12 (1.85) 3.28 (1.41) F(1,58) = 81,33*** .58 >6
Note.
***significant at p<.001;
**significant at p<.01;
*significant at p<.05
E-R: Emotionally Reactive; SL-P: Sleep Problems; A-D: Anxious/Depressed; S-C: Somatic Complaints; WIT: Withdrawn (Withdrawn/Depressed at Time 3); A-P: Attention
Problems; A-B: Aggressive Behavior; R-B: Rule-Breaking Behavior; T-P: Thought Problems; S-P: Social Problems
The last columnreports cut-off scores in the referring population. The second number of CUT-OFF is for CBCL dimensions at Time 3 as CUT-OFF mean betweenmales and female.
Eur. Eat. Disorders Rev. (2012)© 2012 John Wiley & Sons, Ltd and Eating Disorders Association.

5. S. Cimino et al. Mothers with Eating Disorders
Table 4 Hierarchical Regression model: parental dimensions on child’s specific emotional/adaptive outcomes at Time 1
Child’s Anxious/Depressed (T1) Child Withdrawn (T1) Child Aggressive Behavior (T1)
b1 b2 b3 b4 R Ch. r b1 b2 b3 b4 R Ch. r b1 b2 b3 b4 R Ch. r
1 CG/NCG .46*** Ns Ns Ns .22*** .05 .76*** .54** .60* .57** .58*** .76 .71*** .64** .54** Ns .50*** .71
GENDER Ns Ns Ns Ns .49 Ns Ns Ns Ns .00 Ns Ns Ns Ns -.04
2 ANX (M) Ns Ns Ns .12 .55 Ns Ns Ns .03 .61 Ns Ns Ns .09* .64
DEP (M) Ns Ns Ns .48 Ns Ns Ns .73 Ns Ns Ns .68
SOM (M) Ns Ns Ns .53 Ns Ns Ns .64 .44+ .49* Ns .69
PSY (M) Ns .63** .54** .49 Ns Ns Ns .58 Ns Ns Ns .62
3 ANX (F) Ns .64+ .21*** .45 Ns Ns .04 .50 Ns Ns .10** .59
DEP (F) Ns Ns .42 -44** Ns .48 -.60 s -.57 s .56
SOM (F) -.54 s -.40 s .55 Ns Ns .52 Ns Ns .65
O-C (F) .90*** Ns .61 .56* Ns .53 Ns Ns .63
4 DEP (M) * ANX (F) Ns .09** .69 Ns .01 .72 Ns .02 .74
DEP (M) * O-C (F) .70** .05 Ns .76 .67+ .78
R2 .64 .67 .73
AR2 .55 .58 .66
Note. R Ch = R change; b1 = beta at step 1; b2 = beta at step 2; b3 = beta at step 3; b4=final beta; R2 = R Square AR = Adjusted R2;
***significant at p<.001;
**significant at p<.01;
*significant at p<.05;
+significant at p<.09;
Ns = not significant; s = suppression effect; r = zero-order correlations.
(M) = Mother’s dimensions at Time 1; (F) = Father’s dimensions at Time 1; CG/NCG = groups membership (0 = non clinical group; 1 = clinical group);
ANX: Anxiety; DEP: Depression; SOM: Somatization; PSY: Psychoticism; O-C: Obsessive-Compulsive.
Table 5 Hierarchical Regression model: parental dimensions on child’s internalizing and externalizing problems at Time 1
Child’s Internalizing Problems (T1) Child Externalizing Problems (T1)
b1 b2 b3 b4 R Ch. r b1 b2 b3 b4 R Ch. r
1 CG/NCG .72*** .46* .44* .40* 0.53*** .72 .73*** .62** .50**.47* Ns .55*** .74
GENDER Ns Ns Ns Ns .10 Ns Ns Ns Ns -.04
2 ANX (M) Ns Ns Ns .05 .64 Ns Ns Ns .08* .66
DEP (M) Ns Ns Ns .73 Ns Ns Ns .71
SOM (M) Ns Ns Ns .66 .41+ .45* Ns .71
PSY (M) Ns .43+ Ns .64 Ns Ns Ns .64
3 ANX (F) -44 s Ns .11** .57 Ns Ns .09** .60
DEP (F) -42 s -.42 s .54 -.55 s -.53 s .58
SOM (F) Ns Ns .54 Ns Ns .66
O-C (F) .82** Ns .61 .60* Ns .64
4 DEP (M) * ANX (F) Ns .05** .76 Ns .02 .77
DEP (M) * O-C (F) .90*** .82 .64+ .80
R2 .75 .74
AR2 .70 .68
Note. R Ch = R change; b1 = beta at step 1; b2 = beta at step 2; b3 = beta at step 3; b4=final beta; R2 = R Square AR = Adjusted R2;
***significant at p<.001;
**significant at p<.01;
*significant at p<.05;
+significant at p<.09;
Ns = not significant; s = suppression effect; r = zero-order correlations.
(M) = Mother’s dimensions at Time 1; (F) = Father’s dimensions at Time 1; CG/NCG = groups membership (0 = non clinical group; 1 = clinical group);
ANX: Anxiety; DEP: Depression; SOM: Somatization; PSY: Psychoticism; O-C: Obsessive-Compulsive.
significantly to explaining higher scores for children on the sub-scales
of anxiety/depression, aggressive behavior, and both external-izing
and internalizing problems at T3.
An interaction between maternal depression and paternal
obsessive-compulsive dimensions contributed significantly to
explaining children’s both externalizing and internalizing outcomes
Eur. Eat. Disorders Rev. (2012)© 2012 John Wiley & Sons, Ltd and Eating Disorders Association.

6. Mothers with Eating Disorders S. Cimino et al.
Table 6 Hierarchical Regression model: parental dimensions on child’s specific emotional/adaptive outcomes at Time 2
Child’s Anxious/Depressed (T2) Child Withdrawn (T2) Child Aggressive Behavior (T2)
b1 b2 b3 b4 R Ch. r b1 b2 b3 b4 R Ch. r b1 b2 b3 b4 R Ch. r
1 CG/NCG .55*** Ns Ns Ns .31*** .55 .83*** .63** .42** .42** .70*** .83 .72*** .61** .31+ Ns .52*** .72
GENDER .13 Ns Ns Ns .13 Ns Ns Ns Ns -.10 Ns Ns Ns Ns .01
2 ANX (M) Ns Ns Ns .13* .60 Ns Ns Ns .08** .77 Ns Ns Ns .10* .68
DEP (M) Ns Ns Ns .59 Ns Ns Ns .82 Ns Ns Ns .69
SOM (M) Ns Ns Ns .63 Ns Ns Ns .76 .46* .40* .42* .72
PSY (M) .52+ .51+ Ns .63 Ns Ns Ns .71 Ns Ns Ns .64
3 ANX (F) Ns Ns .06 .47 Ns Ns .03+ .62 Ns Ns .15*** .70
DEP (F) Ns Ns .56 Ns Ns .67 -.37 s -.39 s .69
SOM (F) Ns Ns .48 Ns Ns .68 Ns Ns .74
O-C (F) Ns Ns .52 Ns Ns .65 .65** Ns .75
4 DEP (M) * ANX (F) Ns .03 .64 Ns .00 .80 Ns .00 .75
DEP (M) * O-C (F) Ns .69 Ns .80 Ns .78
R2 .55 .82 .77
AR2 .44 .77 .72
Note. R Ch = R change; b1 = beta at step 1; b2 = beta at step 2; b3 = beta at step 3; b4=final beta; R2 = R Square AR = Adjusted R2;
***significant at p<.001;
**significant at p<.01;
*significant at p<.05;
+significant at p<.09;
Ns = not significant; s = suppression effect; r = zero-order correlations.
(M) = Mother’s dimensions at Time 1; (F) = Father’s dimensions at Time 1; CG/NCG = groups membership (0 = non clinical group; 1 = clinical group);
ANX: Anxiety; DEP: Depression; SOM: Somatization; PSY: Psychoticism; O-C: Obsessive-Compulsive.
Table 7 Hierarchical Regression model: parental dimensions on child’s internalizing and externalizing problems at Time 2
Child’s Internalizing Problems (T2) Child Externalizing Problems (T2)
b1 b2 b3 b4 R Ch. r b1 b2 b3 b4 R Ch. r
1 CG/NCG .83*** .69*** .51** .49** .70*** .83 .75*** .61** .32* Ns .56*** .75
GENDER Ns Ns Ns Ns .08 Ns Ns Ns Ns .00
2 ANX (M) Ns Ns Ns .09*** .79 Ns Ns Ns .09** .69
DEP (M) Ns Ns Ns .82 Ns Ns Ns .72
SOM (M) Ns Ns Ns .78 .48* .42* .42* .74
PSY (M) .41* .40* Ns .77 Ns Ns .65
3 ANX (F) Ns Ns .04** .64 Ns Ns .12*** .70
DEP (F) Ns Ns .69 Ns Ns .70
SOM (F) Ns Ns .67 Ns Ns .74
O-C (F) Ns Ns .67 .54* Ns .74
4 DEP (M) * ANX (F) Ns .01 .83 Ns .00 .77
DEP (M) * O-C (F) .54* .87 Ns .80
R2 .86 .78
AR2 .82 .73
Note. R Ch = R change; b1 = beta at step 1; b2 = beta at step 2; b3 = beta at step 3; b4=final beta; R2 = R Square AR = Adjusted R2;
***significant at p<.001;
**significant at p<.01;
*significant at p<.05;
+significant at p<.09;
Ns = not significant; s = suppression effect; r = zero-order correlatioNs.
(M) = Mother’s dimensions at Time 1; (F) = Father’s dimensions at Time 1; CG/NCG = groups membership (0 = non clinical group; 1 = clinical group);
ANX: Anxiety; DEP: Depression; SOM: Somatization; PSY: Psychoticism; O-C: Obsessive-Compulsive.
at all time points except for the externalizing behaviors at T2.
Negative beta coefficients in regression models are explained by
suppression effects, as evidenced by positive correlations
between independent and dependent variables. With the exception
of gender, all dimensions were highly and significantly correlated
(p<.001).
Eur. Eat. Disorders Rev. (2012)© 2012 John Wiley & Sons, Ltd and Eating Disorders Association.

7. S. Cimino et al. Mothers with Eating Disorders
Table 8 Hierarchical Regression model: parental dimensions on child’s specific emotional/adaptive outcomes at Time 3
Child’s Anxious/Depressed (T3) Child Withdrawn/Depressed (T3) Child Aggressive Behavior (T3)
b1 b2 b3 b4 R Ch. r b1 b2 b3 b4 R Ch. r b1 b2 b3 b4 R Ch. r
1 CG/NCG .88*** .93*** .84*** .83*** .78*** .88 .84 .72*** .78*** .74*** .72*** .84 .75*** .44* Ns Ns .56*** .75
GENDER Ns Ns Ns Ns -.06 Ns Ns Ns Ns .07 Ns Ns Ns Ns .04
2 ANX (M) Ns Ns Ns .01 .62 Ns Ns Ns .02 .63 -.70 s -.76 s Ns .08* .53
DEP (M) Ns Ns Ns .78 Ns Ns Ns .76 Ns Ns Ns .71
SOM (M) Ns Ns Ns .65 Ns .53* .41* .69 .67** .64 .48* .64
PSY (M) Ns Ns Ns .57 Ns Ns Ns .55 Ns Ns Ns .51
3 ANX (F) .34* Ns .04* .64 Ns Ns .01 .52 .38+ Ns .05 .60
DEP (F) Ns Ns .59 Ns Ns .53 Ns Ns .56
SOM (F) Ns Ns .63 Ns Ns .56 Ns Ns .56
O-C (F) Ns Ns .61 Ns Ns .52 Ns Ns .02 .58
4 DEP (M) * ANX (F) Ns .01 .81 Ns .03 .75 Ns .76
DEP (M) * O-C (F) Ns .79 .75* .78 Ns .77
R2 .84 .78 .72
AR2 .80 .73 .66
Note. R Ch = R change; b1 = beta at step 1; b2 = beta at step 2; b3 = beta at step 3; b4=final beta; R2 = R Square AR = Adjusted R2;
***significant at p<.001;
**significant at p<.01;
*significant at p<.05;
+significant at p<.09;
Ns = not significant; s = suppression effect; r = zero-order correlations.
(M) = Mother’s dimensions at Time 1; (F) = Father’s dimensions at Time 1; CG/NCG = groups membership (0 = non clinical group; 1 = clinical group);
ANX: Anxiety; DEP: Depression; SOM: Somatization; PSY: Psychoticism; O-C: Obsessive-Compulsive.
Table 9 Hierarchical Regression model: parental dimensions on child’s internalizing and externalizing problems at Time 3
Child’s Internalizing Problems (T3) Child Externalizing Problems (T3)
b1 b2 b3 b4 R Ch. r b1 b2 b3 b4 R Ch. r
1 CG/NCG .91*** .83*** .84*** .81*** .82*** .91 .80*** .54** .46** .42* .65*** .80
GENDER Ns Ns Ns Ns -.02 Ns Ns Ns Ns .04
2 ANX (M) Ns Ns Ns .02 .66 -.58* -.61* -.52* .06* .61
DEP (M) Ns Ns Ns .82 Ns Ns Ns .76
SOM (M) Ns Ns Ns .69 .55** Ns .39+ .70
PSY (M) Ns Ns Ns .60 Ns Ns Ns .58
3 ANX (F) Ns .40* .02 .60 Ns .52* .05* .61
DEP (F) Ns Ns .57 Ns Ns .60
SOM (F) Ns Ns .59 Ns Ns .58
O-C (F) Ns Ns .59 Ns Ns .61
4 DEP (M) * ANX (F) Ns .03* .82 Ns .04** .80
DEP (M) * O-C (F) .63** .83 .87** .84
R2 .87 .80
AR2 .85 .76
Note. R Ch = R change; b1 = beta at step 1; b2 = beta at step 2; b3 = beta at step 3; b4=final beta; R2 = R Square AR = Adjusted R2;
***significant at p<.001;
**significant at p<.01;
*significant at p<.05;
+significant at p<.09; Ns = not significant; s = suppression effect; r = zero-order correlations.
(M) = Mother’s dimensions at Time 1; (F) = Father’s dimensions at Time 1; CG/NCG = groups membership (0 = non clinical group; 1 = clinical group);
ANX: Anxiety; DEP: Depression; SOM: Somatization; PSY: Psychoticism; O-C: Obsessive-Compulsive.
Discussion
Several interesting issues emerge from our results. First, our study
indicates that mothers in the CG had higher psychopathological
risk in their psychological profiles than mothers in the NCG at
all assessment time points. These scores were stable over time,
with the exception of depressive symptoms in mothers in the
CG, who showed a tendency for a linear increase from T1 to
Eur. Eat. Disorders Rev. (2012)© 2012 John Wiley & Sons, Ltd and Eating Disorders Association.

8. Mothers with Eating Disorders S. Cimino et al.
T3. Our results are consistent with the literature in indicating that
maternal EDs are often associated with depressive symptoms that
tend to persist over time, leading to a higher psychopathological
risk in this area if left untreated (Bagner et al., 2010; Micali
et al., 2011). We further found that fathers in the CG had higher
psychopathological risk than fathers in the NCG over the course
of the study. Although we observed a decrease in the scores
at T2, several subscales exceeded the cut-offs for the Italian
population at T2 as well, suggesting an essentially stable psycho-pathological
risk in some areas within a complex and variable
configuration.
Regarding our second objective, children in the CG showed a
compromised emotional profile at all of the assessment sessions.
This finding fits well with other studies indicating that maternal
EDs may constitute a relevant risk factor for maladaptive func-tioning
in children (Cooper et al., 2004). Children of women with
EDs have been described in the international literature as opposi-tional,
aggressive, withdrawn, and showing severe anxiety and
depressive symptoms (Dietz, Jennings, Kelley, & Marshal, 2009;
Watkins et al., 2012).
Consistent with the results of Patel, Wheatcroft, Park, and Stein
(2002), we found that maternal psychopathology, namely the ED,
is the crucial issue that influenced children’s maladaptive func-tioning
at all assessment time points. The specific characteristics
of somatization in the mothers’ psychological profiles seem to
predict withdrawal/depression, aggressive behavior, and external-izing
problems in children. This result is consistent with several
studies that have suggested that somatization may be considered
a typical issue in the clinical profile of women with EDs (Peñas-
Lledó, Vaz Leal, & Waller, 2002).
Moreover mothers’ psychoticism affected children’s anxiety/
depression subscales at both Time 1 and Time 2. This result is
coherent with the study of Riahi, Amini, and Salehi Veisi (2010),
that points out the effect of mothers’ psychoticism symptoms on
internalizing behaviors of their children.
Interestingly, our data further suggest that specific paternal
psychological profiles, particularly anxiety and obsessive/compul-sive
symptoms, may predict problematic issues in a child’s global
functioning, both in internalizing and externalizing areas. Consis-tent
with the present findings, Dietz et al. (2009) have provided
empirical evidence of the presence of psychopathologic symptoms
in the partners of women with EDs that can facilitate the onset of
emotional disorders in their children.
Finally, it is interesting that maternal depressive symptoms only
influenced maladaptive functioning of children in the CG when
paternal obsessive-compulsive symptoms were present. This
finding supports prior findings by Dietz et al. (2009) and Bagner
et al. (2010) showing that adverse outcomes in children exposed
to maternal depressive symptoms are also dependent upon the
presence of paternal psychopathological risk.
Strengths and limitations
This study addressed the relatively unexplored topic of the role of
fathers’ psychopathological risk in the outcome of children of
mothers with EDs, and in the emergence of psychological distur-bances
in these children. We employed a longitudinal design with
a matched control group and all of the measures used had been
well validated previously.
Our work has some limitations. Firstly, we did not administer
the SCID-II to assess personality disorders in the mothers and
we did not evaluate the severity of the mothers’ EDs with a spe-cific
tool. Subjects in the NCG were paired post hoc with subjects
in the CG, and N= 26 families in the NCG were not included in
our analysis. These limitations will constitute a motivation to
continue our research, also taking into consideration samples of
mothers with comorbidities including a diagnosis of clinical
depression.
Conclusions and clinical implications
The key feature of the present study is the focus on the role of pater-nal
psychological profiles on children’s maladaptive functioning in a
sample of families of mothers with EDs. This study has its most
significant implications in the planning of assessment protocols
for mothers with EDs, which we suggest should consider the role
of the partner. Consistent with the findings of Sarkadi, Kristiansson,
Oberklaid, and Bremberg (2008), our data reinforce the importance
of longitudinal studies that take into consideration the possible
fluctuation of scores in specific areas of psychopathological risk.
This approach could aid in the development of more accurate
assessment and intervention protocols.
To help ameliorate negative outcomes of children’s emotional
development, clinicians should consider the whole family context,
especially when the father shows anxiety in his psychological
profile. To this end, we propose that when mothers with EDs
are assessed, their partners’ psychological profiles should also be
assessed to mitigate possible psychopathological outcomes in their
children. These empirical conclusions are coherent with the
clinical work of Kohut, who emphasized how the disturbances
of an individual’s Self are always related to a two-fold, severe
and continuative failure of that person’s mother and father
(1971, The Analysis of the Self).
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