Department of Psychology, University of Reading,UK
Correspondence: Professor Peter J. Cooper, Winnicott Research Unit, Department of Psychology, University of Reading, Whiteknights, Reading RG6 6AL, UK. E-mail: P.J.Cooper{at}reading.ac.uk
See editorial, pp.
195-196, this issue.
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ABSTRACT |
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Aims To elucidate family-environmental factors that could mediate this association.
Method A general population sample of children with feeding problems (n=35), other problems (shyness, fears or behavioural problems; n=58), or no problems (n=23) was identified. The mental state of their mothers was evaluated, including an assessment of current and past eating disorder. Video recordings were made in the families homes of a mealtime and of the mothers and children participating in a standardised exploratory task.
Results Two family-environmental variables significantly distinguished the children with feeding problems from the other two groups: mealtime disorganisation and maternal strong control and disharmony. Path analysis revealed the importance of these two environmental variables in mediating the association between child and maternal disturbance.
Conclusions The degree of mealtime disorganisation and the level of maternal strong control and disharmony mediate the association between maternal eating disorder and child feeding disturbance.
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INTRODUCTION |
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METHOD |
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Two comparison samples were identified for further study (from the same ten schools, plus two further schools). First, out of the full sample of 578 completed BSQs (out of a possible 867), a random sample of 1 in 10 (i.e. 44) of those who fulfilled criteria for a normal control sample (i.e. no marked feeding problem, fearfulness, shyness or behavioural disturbance) was selected for further study: 5 mothers could not be contacted (no telephone or wrong address) and 10 refused to take part in the study. The remaining 29 children were assessed, and formed the normal control subgroup of this study. Second, a disturbed comparison sample was identified: this comprised children who had no reported feeding problem, but who were reported to be fearful (three or more marked fears, or six or more mild fears on the BSQ or the PBCL), shy (mean score of 4.0 or more on the child shyness questionnaire) or to have significant behavioural disturbance (score of at least 10 on the BSQ or 12 on the PBCL, together with marked disturbance in at least one of the key areas of disturbance), or any combination of these three categories. A total of 95 English-speaking children fulfilled these criteria and were selected for further study: 10 mothers could not be contacted (no telephone or wrong address) and 6 refused to take part in the study, leaving 79 children in the disturbed subgroup.
Maternal assessment
The mothers and children were assessed on two separate occasions in their
own homes. A combination of interview, questionnaire and systematic
observational measures was used. The eating behaviour of all the children was
assessed by maternal interview, using the Feeding Problems and Eating
Disorders Interview Schedule (Harris &
Booth, 1992), a reliable and valid method of assessing child
feeding problems. In all the cases of feeding problems identified by the
mother on the BSQ (bar the one excluded case referred to above), the feeding
disturbance was confirmed at this interview. Furthermore, although in some of
the children in the two comparison groups disturbances in feeding of a minor
nature were identified by this interview, in no case did this approach the
severity found in those within the feeding problems group. In addition to this
interview, a family meal was filmed and rated (see below).
Two additional standardised interviews were used to assess the mothers: the Eating Disorder Examination (EDE; Cooper et al, 1989), which provides a detailed assessment of eating habits and attitudes (and a self-reported account of height and weight), and the Anxiety Disorders Interview Schedule (Brown et al, 1994), which provides an assessment of DSM-IV anxiety and depressive disorders (American Psychiatric Association, 1994). For both measures an assessment of current state was made, as well as an assessment of lifetime psychiatric history. For each woman interviewed, DSM-IV diagnoses were made by the interviewer in consultation with one of the authors (P.J.C.). The rates of current and past DSM-IV Axis I disorders among the mothers of the three groups of children in this study have been reported in an earlier paper (Whelan & Cooper, 2000). Three interviewers carried out the maternal mental state assessment masked to child status; in a few cases this could not be completed. The following results concern the sub-sample of 116 mother-child pairs for whom full maternal mental state and observational data were available: 35 from the feeding problems sample, 58 from the disturbed sample and 23 from the normal sample.
Observational assessment
The mealtime observations served two purposes: the first was to validate
the childrens assignment to the feeding problem category, and the
second was to investigate the nature of the mother-child relationship in the
context of child feeding. The mothers were asked to give their child their
normal midday meal, and if the two normally ate together, then to do that
also. The meal was recorded by video camera, with the researcher in another
room to allow the participants to behave naturally. The mother was asked to
call the researcher when the meal finished so that filming could be stopped.
The childrens mealtime behaviour was then coded (with the assessor
masked to child group and maternal mental state), according to a system based
upon items drawn from the Feeding Problems and Eating Disorders Interview
Schedule: food refusal, faddiness, amount eaten and eating behaviour (e.g.
spitting).
The filmed meal was also used to rate maternal management style. Six items
relating to the environment and management of the childs mealtime were
selected in order to assess the specific dimension of mealtime
disorganisation: these items were location (kitchen or dining room),
disposition (table and chair), presence of mother, mother eating with the
child, child eating with siblings, and distractibility (e.g. watching
television or play with toys). These six items were aggregated to form a
single scale, which had adequate internal consistency (=0.63).
In addition, the mothers and children were filmed interacting in a
situation unrelated to eating: this was a task in which the children were
instructed to explore the contents of a box, under conditions of apprehension,
and the mother was instructed to assist them. A coding system was devised to
assess the degree of strong maternal control and disharmony (Stein et
al, 1994,
1996). An index was derived by
aggregating the standardised (z) scores of three variables: physical
interventions, strong verbal directives and overall level of disharmony.
Again, ratings were made masked to both child group and maternal psychiatric
history. This index also had adequate internal consistency (=0.66).
Statistical analyses
Path analytic techniques were employed to investigate the potential
mediating role of the mother-child relationship variables (mealtime
disorganisation and strong control/disharmony) in the association between
maternal eating disorder psychopathology and child feeding problems. The data
were modelled using the M-plus software package
(Muthen & Muthen, 1998)
using weighted least squares estimation with robust standard errors and
assessed with the mean and variance adjusted chi-squared statistic. This
modelling technique allows analyses to be conducted using categorical
variables, and the use of robust estimators gives reliable estimations when
the variable distributions are skewed and sample sizes are small
(Bentler & Yuan, 1999).
With the use of robust estimators, it is not possible to test the suitability
of different models using the conventional approach of 2
difference testing; thus models were compared according to other model fit
indices, specifically the root mean square error of approximation (RMSEA), the
comparative fit index (CFI) and the non-normed fit index (NNFI). For the
RMSEA, values below 0.08 indicate a satisfactory fit and values below 0.05
indicate an excellent fit. For both the CFI and the NNFI, values above 0.95
indicate a satisfactory fit.
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RESULTS |
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Validation of the presence of feeding problems
Because membership of the feeding problems group was based entirely on
mothers reports on the BSQ of their childs problems, the
possibility had to be considered that the reporting of child faddiness or
appetite disturbance was a factitious projection made by the mothers rather
than a feature of the children themselves. If such projection were
systematically related to maternal eating disorder psychopathology, then any
relationship found between child and maternal disturbance would be spurious,
and the search for mediators would be folly. To eliminate this possibility,
child behaviour during the filmed family meal was rated masked to both child
group and maternal mental state. On the index of child feeding disturbance,
the children in the feeding problems group were rated as significantly more
disturbed than both the disturbed comparison children and the normal control
children (2=20.6, d.f.=2, P<0.05 on post
hoc tests for both comparisons). Furthermore, for the whole group of
children, there was a strong relationship between the degree of feeding
disturbance reported by the mother on the BSQ (using the ordinal scale
described above) and the degree of disturbance in feeding evidenced by the
child at the filmed meal (r=0.51, P<0.001). Notably, this
relationship between maternally reported and independently observed child
feeding disturbance was unrelated to the level of eating disorder
psychopathology in the mother. Compared with the simple correlation between
reported and observed child feeding problems, the partial correlation
coefficient, controlling for the effect of current maternal EDE total score,
was minimally changed (at 0.46); and controlling for maternal DSM-IV eating
disorder history, the decrease was nugatory (i.e. from 0.51 to 0.48). These
findings indicate that maternal reports of child feeding disturbance were
unrelated to eating disorder psychopathology in the mother, and that the group
of children identified by their mothers as having feeding problems did indeed
have disturbed eating patterns.
Observational measures
The three study groups were compared on the two indices of the mother-child
relationship: mealtime disorganisation
(Fig. 1) and strong
control/disharmony (Fig. 2). On
both indices, ratings were significantly higher for the feeding problems group
than for the other two groups (F(2,113)=9.88,
P<0.001 and F(2,113)=7.26, P<0.001
respectively), with post hoctests indicating that the feeding
problems group was significantly different from the other two groups (and that
the other two groups were no different from each other).
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Path analysis
A child feeding problems variable was derived from the two relevant BSQ
items and applied to the full sample of 116 children. This four-point ordinal
scale corresponded to no problems (score of 0 on both BSQ
items), minor problems (of 1 on either or both BSQ items),
moderate problems (score of 2 on one of the two BSQ items) and
marked problems (a score of 2 on both BSQ items). The number of
children within each level was 44 (no problem), 36 (minor problem), 23
(moderate problem) and 13 (marked problem). The path analysis included only
those children for whom complete data were available on the four critical
variables: level of child feeding disturbance, current and past maternal
eating disorder, mealtime disorganisation and maternal strong
control/disharmony. This produced a sample of 116 children: 35 from the
feeding problems group, 58 from the disturbed group and 23 from the normal
control group.
Table 1 shows the univariate
correlation matrix between the four critical variables. As hypothesised, both
the presence of current maternal eating disorder psychopathology (i.e. EDE
total score) and the two mother-child relationship variables were
significantly associated with the extent of the feeding problem in the child.
In addition, the two relationship variables were also significantly associated
with the level of maternal eating disorder psychopathology. In order to
investigate whether the mother-child relationship variables mediated the
relationship between maternal eating disorder psychopathology and child
feeding problems, a path analysis was conducted. A model was specified in
which child feeding problems were predicted by the severity of current
maternal eating disorder psychopathology, mealtime disorganisation and
maternal strong control/ disharmony; and both mealtime disorganisation and
maternal strong control/disharmony were predicted by the severity of maternal
eating disorder psychopathology. This model provided a satisfactory level of
fit according to all three model fit indices: 2=0.55, d.f.=1,
P=0.485; RMSEA=0.062, CFI=0.989, NNFI=0.960
(Fig. 3). In contrast to the
univariate direct relationship between maternal eating disorder
psychopathology and child feeding problems, the multivariate analysis showed
that this direct pathway was no longer significant. It therefore appeared that
the two mother-child relationship variables fully mediated the continuity
between maternal eating disorder psychopathology and child feeding problems.
Furthermore, when this mediational model was tested explicitly by fixing the
direct pathway to zero and rerunning the analysis, the model fit indices
showed additional improvement:
2=1.421, d.f.=2,
P=0.488; RMSEA=0.049; CFI=0.990; NNFI=0.974. Specifically, the RMSEA
fell below the critical cut-off value of 0.05 for an excellent fit.
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DISCUSSION |
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Contribution of the family environment to family aggregation
The research on the contribution of the family environment to the
intergenerational transmission of eating disorders is limited in both quantity
and quality. Some case reports suggest an adverse impact of anorexic and
bulimic behaviour on both foetal development and infant growth (e.g.
Treasure & Russell, 1988), and of an adverse effect of bulimia nervosa on parenting (e.g.
Stein & Fairburn, 1989).
However, there has been only one systematic study of the impact of maternal
eating disorder on early caregiving and infant developmental progress (Stein
et al, 1994,
1996). In this study mothers
with eating disorders and their year-old infants were compared with a control
group of mothers and infants during both feeding and playing. At mealtimes
mothers with eating disorders were found to be more intrusive, and there was
more conflict between these mothers and their infants, compared with the
control group; they were also more likely to be intrusive and controlling
during play. In addition, the year-old infants of the mothers with eating
disorders were significantly lighter than similarly aged infants of normal
mothers and of mothers who had experienced postnatal depression
(Stein et al, 1996).
The extent to which these disturbances in the early mother-infant relationship
were related to the development of disturbances in eating in the child remains
to be clarified by further longitudinal work.
Specificity in intergenerational transmission
Some evidence of specificity in intergenerational transmission comes from
bottom-up studies. Thus, Pike & Rodin
(1991), in a community sample
of girls attending high school, found that those with disordered eating had
mothers who (in comparison with the mothers of girls with no eating
disturbance) themselves had disturbed eating habits and attitudes, and were
more critical of their daughters weight and appearance. The clearest
bottom-up evidence of inter-generational transmission comes from two studies
of children with feeding problems (Stein
et al, 1995; Whelan
& Cooper, 2000). In the earlier study, profiles on the
self-report version of the EDE were compared between three groups: mothers of
young children who had been referred to an out-patient child psychiatry clinic
with a feeding disorder; mothers of children referred to the same clinic with
a non-feeding form of behavioural disturbance; and mothers of a normal control
group of children. On all the EDE sub-scales (restraint, bulimia, eating
concern, weight concern and shape concern), the mothers of the children with
feeding disorders had significantly higher mean scores than the mothers of the
children from both the normal and the behaviourally disturbed control groups.
The findings from this clinic-based study have recently been confirmed and
extended in a community study, which avoids the problems of referral bias
inherent in clinic samples. In a sample of children identified as having a
feeding problem, the odds of a history of a maternal eating disorder were
substantially higher than among the mothers of children with non-feeding forms
of disturbance (Whelan & Cooper,
2000).
The latter two studies suggest a specific association between maternal eating disorders and child feeding problems, and they suggest that intergenerational transmission may manifest itself early in child development. Clinically, this suggests that comprehensive assessment of children presenting with feeding problems should routinely include an assessment of the mothers eating history. Scientifically, it raises the question of the mechanism by which this relationship between child and maternal disorder is established and maintained. The rather modest contribution of genetics to the familiality of eating disorders (Fairburn et al, 1999) suggests that the family environment might well have a significant role. The fact that the parenting of infants of mothers with bulimia nervosa is disturbed, especially in relation to child feeding (Stein et al, 1994, 1996), provides some empirical basis for such speculation. There is, however, surprisingly little other empirical support for this idea in the research literature.
Findings of this study
Our study indicated that two aspects of the family environment were
strongly associated with the presence of child feeding problems: mealtime
disorganisation, and a mother-child relationship characterised by strong
maternal control and disharmony. For both these variables the group of
children with feeding problems was clearly distinguished from both the normal
control group and the disturbed comparison group. Although it is certainly
possible that for both of these variables the disturbances identified were
secondary to the child feeding problem, this is not a likely account of the
basis to the associations found. The variables that made up the
mealtime disorganisation index were, in the main, gross
descriptors of the home environment and the process of family meals. Whether
the meal was served at a table with chairs, whether or not the mother ate with
the child, and whether the meal was eaten in front of a television, are
unlikely to have been influenced by the childs own eating behaviour.
The maternal strong control/disharmony index was also unlikely
to have been substantially influenced by the extent of child feeding
disturbance, since this variable was derived from a task that had nothing to
do with food or eating. It seems, therefore, plausible that these two indices
of family disturbance were factors that could have contributed to the
development and maintenance of child feeding problems.
The path analysis revealed that the two family-environmental variables did, indeed, mediate the relationship between maternal eating disorder psychopathology and the level of child feeding disturbance. This suggests a mechanism for the transmission of feeding disturbance from mother to child: it appears that mothers with high levels of eating disorder psychopathology tend to provide a disorganised mealtime environment for their children and tend to have a controlling and disharmonious style of interacting with them, and in this context children are likely to develop disturbed eating habits such as faddiness and refusal.
Whether the processes elucidated in our study have any bearing on the intergenerational transmission of DSM-IV eating disorders remains an entirely open question, one that hangs on the relationship between early childhood feeding disturbance and later frank eating disorder. There is little previous research to illuminate this question, and the few findings that have been reported have been conflicting. Thus, Mitchell et al (1986) reported that the mothers of patients with bulimia nervosa rarely could identify a significant feeding problem before the onset of the eating disorder; Jacobs & Isaacs (1986), on the other hand, found that their patients with prepubertal anorexia nervosa had a higher rate of childhood feeding problems than both patients with anorexia nervosa of classical post-pubertal onset and a pre-pubertal group of patients with a non-eating form of disturbance. The most commonly cited evidence for an association between early feeding problems and later eating disorders comes from a study reported by Marchi & Cohen (1990). They reported early pica to be predictive of later bulimia nervosa, and early picky eating to predict adolescent anorexia nervosa. However, although this study was longitudinal, assessments were made at a range of ages and the data were not truly prospective. Elucidation of this issue therefore awaits the findings of a systematic, prospective longitudinal study.
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Clinical Implications and Limitations |
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LIMITATIONS
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ACKNOWLEDGMENTS |
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Received for publication October 4, 2002. Revision received February 19, 2003. Accepted for publication March 4, 2003.
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