Relationship between parental perfectionism and child’s disordered eating: mediating role of parental distress and validation of the arabic version of the eating disorders examination questionnaire-short-parent version (EDE-QS-P) | BMC Psychiatry

Our study objectives were twofold: (a) to assess the mediating effect of parental distress in the association between parental perfectionism and children’s DE; and (b) to examine the psychometric properties of an Arabic translation of the EDE-QS-P scale within the Lebanese context. The two study hypotheses were supported.

Psychometric properties of the arabic version of the EDE-QS-P

The absence of other parent-report measures for convergent validity restricts our comprehensive understanding of the scale’s validity. Relying on a single validation study [10] for comparison limits the depth of insights into the scale’s performance across diverse contexts. Furthermore, not involving children in completing the EDE-QS for convergent validity assessment with parent scores on the EDE-QS-P impedes our exploration of potential discrepancies between parent and child perspectives. Future validation efforts should consider broader measures, involving both parents and children, to enhance the scale’s cross-cultural applicability.

Multi-group CFA for parents’ sex measurement invariance testing revealed that the EDE-QS-P was invariant between mother and father respondents, which means that items are interpreted in the same way across sexes. It’s notable that our study revealed higher EDE-QS-P scores reported by fathers compared to mothers, shedding light on the limited research addressing fathers’ perspectives and roles in children’s eating behaviors [31]. A possible explanation for this discrepancy can be found in previous literature, where mothers reported higher scores in unhealthy eating attitudes, perceived feeding responsibility, and monitoring of their child’s feeding [56]. This suggests that mothers may have different concerns or perceptions regarding their child’s eating behaviors, which could account for the differences observed in our study.

Furthermore, our study’s findings on higher EDE-QS-P scores reported by Lebanese fathers compared to mothers may be influenced by entrenched societal norms. On one hand, this could be explained by fathers’ lesser awareness of promoting healthy eating habits, leading them to relinquish responsibility to their spouses [57]. In many Lebanese communities, women primarily shoulder responsibilities for homemaking and traditionally feminine tasks, including cooking and managing children’s diets [58, 59]. Fathers, often preoccupied with external responsibilities as breadwinners, may have limited involvement in daily childcare [60]. As a result fathers may not notice eating behaviors as closely as mothers, who are more present at home. This can lead to fathers providing less accurate assessments or having a different perspective on their child’s eating habits. On the other hand, differences in communication styles and patterns between fathers and mothers may affect their willingness to report concerns about their child’s eating behaviors. Fathers might be more direct or assertive in expressing their observations, whereas mothers might be more inclined to downplay or overlook certain behaviors [61]. As a result, fathers may report higher EDE-QS-P scores reflecting a more candid assessment of their child’s disordered eating symptoms.

The mediating role of parental distress between parental perfectionism and child’s DE

Following the successful validation of the EDE-QS-P scale, we delved into the second aspect of our study, aiming to understand the mediating role of parental distress in the association between parental perfectionism and children’s disordered eating. Our findings confirm the hypothesized pathway, with higher levels of parental perfectionism correlating with increased parental distress, which, in turn, was associated with elevated levels of the child’s DE. Additionally, higher parental perfectionism directly links to more instances of a child’s DE.

This study revealed that a significantly higher perfectionism in parents was directly associated with higher frequency of disordered eating in children. Perfectionistic parents may adopt parenting styles characterized by high expectations, pressure for achievement, and an emphasis on appearance or success [62]. Such parenting styles can create an environment that increases the risk of developing eating disorders [16, 62]. Children may feel compelled to meet their parents’ high standards, leading to maladaptive behaviors such as restrictive eating, binge eating, or compulsive exercise as they strive for perfection [62, 63]. Furthermore, parental expectations, high standards, criticism, and controlling feeding behaviors, including physical prompts, coercive policies (bribes, rewarding), forced feeding, and other pressuring measures [17, 63, 64], may contribute to perfectionism in young people and subsequently lead to the development of DE [63, 64]. This phenomenon can also be understood through the lens of Mara Selvini Palazzoli’s theory, which emphasizes a family environment characterized by an intrusive, intolerant, and hypercritical mother, alongside a brilliant but absent father. In such settings, individuals often express their discomfort through abnormal eating behaviors, which provide a sense of control and self-affirmation while simultaneously reinforcing feelings of dependence and loneliness [16, 65].

Building on the observed association between heightened perfectionism in parents and an increased risk of DE symptoms in children, our study also highlights a noteworthy correlation. Specifically, we find that elevated levels of parental perfectionism are significantly linked to heightened parental psychological distress. This finding suggests that perfectionistic tendencies, characterized by excessively high standards, self-criticism, and fear of failure, can contribute to elevated levels of stress, anxiety, and other forms of psychological distress among parents [66, 67]. These results align with the existing literature indicating that perfectionism is often associated with negative psychological outcomes in adults [67, 68].

Our study reveals that the distress experienced by perfectionistic parents serves as a mediator in the pathway to children’s disordered eating. The pursuit of unattainable standards and the fear of failure inherent in perfectionism create a breeding ground for heightened psychological distress in parents [67, 68]. This distress, in turn, becomes a catalyst for maladaptive behaviors in their children [2, 16, 30, 31]. The emotional burden carried by parents, characterized by stress, anxiety, and self-criticism, potentially magnifies the impact of perfectionism in the family environment [69]. This heightened distress may manifest in parenting styles marked by excessive control, pressure for achievement, and critical communication, contributing to an environment conducive to the development of eating disorders in children [17, 62,63,64].

Strengths and limitations

Our study successfully adapted and validated the EDE-QS-P scale for use in Lebanon, ensuring its cultural relevance. The comprehensive evaluation confirmed the scale’s robust psychometric properties, highlighting its reliability and validity in assessing parental disordered eating behaviors. However, the study has limitations. Data collected from parents reporting their children’s EDs symptoms may be susceptible to social desirability bias, as parents might be inclined to report negatively due to criticism of their parenting style [70]. While parent-reported measures provide valuable insights into children’s disordered eating behaviors, potential inaccuracies from recall bias or differing interpretations must be considered. Parents may underreport or exaggerate symptoms based on personal beliefs or guilt [71], which can limit the reliability of the findings. Nevertheless, these limitations do not undermine the importance of parental reports, which offer a unique perspective crucial for understanding child behaviors. It is, however, important to acknowledge the lack of child self-report measures in the current study, which may limit the depth of understanding regarding children’s own experiences and perceptions. Future research should incorporate multi-informant approaches, such as self-reports and clinician assessments, to improve the robustness and balance of the findings.

The snowball technique followed in the data collection, along with the unknown refusal rate, predisposes the study to a selection bias. Additionally, the online enrollment method may limit the representativeness of the general Lebanese population, as it requires internet access and digital literacy, which may be unevenly distributed across the country. Although efforts were made to disseminate the survey broadly, some demographic groups may be underrepresented. Furthermore, the sample predominantly consists of women, many of whom are well-educated and around their 30s, which may introduce selection bias. Despite its cross-sectional design, this study cannot infer causality and cannot give an idea about the baseline measures of the mediator and outcomes, which is important for decreasing the bias when estimating mediational role [72]. However, the mediation analysis can provide exploratory insights into potential associations between variables and can serve as a foundation for future cohort studies. Confounding bias is also present since not all factors associated with disordered eating in children were considered in this study. Additionally, while the study’s reliance on the one-factor EDE model, provides valuable insights, it also highlights the need for further investigation to explore the complexities of disordered eating in children more thoroughly. Lastly, while our study provides valuable insights into parental perceptions of disordered eating behaviors, we did not fully assess all family dynamics. Notably, the results indicated that single parents reported more avoidant restrictive eating in their children compared to married parents. This suggests that family composition may influence parental perceptions and reporting. However, our study did not explore other aspects of family structure, such as the presence of additional children or overall family composition. Future research should include these factors to achieve a more detailed understanding.

In addition, the broader relevance of these findings lies in their potential application to other non-Western or culturally diverse contexts. Although cultural perceptions of eating behaviors and parental roles may differ, the psychometric properties of the EDE-QS-P could still be of value in measuring parental perceptions across diverse populations. The study suggests that the adaptation of such tools to specific cultural settings is crucial for ensuring their accuracy and reliability. By validating instruments like the EDE-QS-P in various cultural contexts, future research could build a more global understanding of parental involvement in disordered eating behaviors and enhance prevention and intervention strategies in non-Western societies.

Clinical implications

The validation of the EDE-QS-P as a measure provides healthcare providers with a reliable tool to assess eating disorders symptomatology in Lebanese children. Given its strong internal reliability and high convergent validity, the EDE-QS-P can effectively be utilized by parents in clinical settings for early detection and monitoring of disordered eating symptoms in Arabic children.

Additionally, the association between parental perfectionism and psychological distress, as well as their impact on children’s eating disorder risk, emphasizes the importance of addressing parental psychological factors in clinical practice. Healthcare providers should be alert to signs of perfectionism and psychological distress in parents and provide appropriate interventions, such as cognitive-behavioral therapy or stress management techniques, to alleviate these issues and reduce their impact on children’s mental health.

Clinicians could also integrate psychological interventions aimed at perfectionism into treatment plans for parents, as addressing these tendencies can enhance family functioning and lower the risk of eating disorders in children. Family therapy can be especially effective in addressing these dynamics, helping families recognize and challenge maladaptive patterns, including perfectionism, body dissatisfaction, and maladaptive thought patterns like overvigilance and inhibition. By targeting these underlying issues, clinicians can promote healthier ways of thinking and adaptive emotional regulation, benefiting both parents and children [23].

Moreover, cognitive restructuring techniques could be used to help parents identify and challenge maladaptive perfectionistic beliefs. Parents who struggle with unrealistic expectations—both for themselves and their children—may benefit from reframing self-critical thoughts and adopting more compassionate perspectives. Self-compassion training, in particular, can be a valuable intervention for parents who experience chronic self-doubt or guilt related to their caregiving role. Encouraging parents to replace rigid, outcome-focused thinking with more process-oriented approaches may alleviate psychological distress, foster healthier parent-child relationships, and enhance overall well-being. This, in turn, may serve as a preventive measure against the development of eating disorders [73, 74].

Structured sessions can focus on improving communication, resolving conflicts, and encouraging collaborative problem-solving among family members [75]. Teaching parents stress management techniques—such as relaxation strategies, time management, and healthy coping mechanisms—could reduce household tension and mitigate the impact of parental distress on children. Clinicians should also incorporate psychoeducation tailored to family needs, such as practical activities like meal planning, to promote healthier routines. By engaging families in therapeutic processes, clinicians can create a supportive and predictable environment that benefits both parents and children [76, 77].

Incorporating mindfulness-based interventions could further support parents in managing perfectionistic tendencies and distress. Practices like guided breathing exercises, body scans, and mindful eating can help parents develop greater emotional awareness and reduce reactivity to stressors [78]. By fostering present-moment awareness, these techniques encourage more balanced and flexible parenting, contributing to a healthier home environment [69]. Additionally, mindfulness-based strategies can help children build resilience against disordered eating patterns by enhancing emotional regulation and reducing anxiety around food-related situations [79, 80].

Public health strategies could also include education campaigns raising awareness of the role of perfectionism and parental stress in the development of eating disorders [16]. These initiatives could focus on stress management, parenting practices and providing supportive home environments. Collaboration among schools, healthcare providers, and community organizations to offer workshops and resources could further support these efforts.

The medium-to-large effect size observed in this study emphasizes the practical significance of these findings and suggests that targeting parental factors could lead to meaningful improvements in both family dynamics and child outcomes, further supporting the clinical applicability of these interventions.

Furthermore, individuals with disordered eating may use a distinct lexicon to articulate their experiences. For instance, terms like “eating,” “weight,” and “eat” are prominent among people with Anorexia Nervosa, reflecting a focus on specific aspects of their condition [81]. This highlights the importance of psychoeducation, as clinicians and parents should be aware of the specific language and terminology in children’s dialogue. Such awareness can enhance communication and support for children and their families. Future studies should focus on exploring more key themes within the language used by children with disordered eating to further inform clinical practice.

Lastly, integrating digital tools, such as online therapy modules, can offer accessible and flexible interventions for both parents and children. These platforms can provide structured support, including psychoeducation, mindfulness exercises, and stress management techniques, which can be accessed remotely and at one’s own pace. Online modules may serve as a complement to in-person therapy, particularly for families with limited access to traditional services or those who prefer the convenience and privacy of digital formats. Digital tools can also be designed to reinforce therapeutic strategies, such as mindfulness-based practices, and offer continuous support between sessions [82,83,84]. Recent studies show that digital platforms integrating evidence-based practices through online therapy, such as Embodied Online Therapy, extend the benefits of traditional therapy into an accessible virtual format. This approach facilitates the adaptation of body-centered techniques, including mindfulness, grounding exercises, and emotional regulation strategies [85], making it a promising tool for managing both parental distress and perfectionism, as well as children’s mental health and disordered eating.