Leopold Muller Centre for Child and Family Mental Health, Department of Paediatrics and Child Health, Royal Free and University College Medical School, London
Department of Psychology, University of Reading
Leopold Muller Centre for Child and Family Mental Health, Department of Paediatrics, Royal Free and University College Medical School, London
Park Hospital for Children, Oxfordshire Mental Healthcare NHS Trust, Oxford
Department of Psychiatry, University of Oxford, Oxford, UK
Correspondence: Professor Alan Stein, Leopold Muller Centre for Child and Family Mental Health, Department of Paediatrics and Child Health, Royal Free and University College Medical School, Royal Free Site, Rowland Hill Street, London NW3 2PF, UK. Fax: +44 (0)20 7447 3789; e-mail: Astein{at}tavi-port.org
Declaration of interest The study was funded by the Wellcome Trust.
See editorial, pp.
9394, this issue.
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ABSTRACT |
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Aims To examine the nature and specificity of maternal controlling behaviour in mothers with eating disorders compared with mothers who had experienced postnatal depression and a healthy comparison group.
Method Mothers with eating disorders (n=34), postnatal depression (n=39) and a healthy comparison group (n=61) and their 12-month-old infants were observed during play and mealtimes, and blind ratings made of verbal and non-verbal control exerted by the mother.
Results Mothers in the eating disorder group used more verbal control, especially strong control. There were no differences between the groups on gentle verbal control and physical contact. Maternal dietary restraint was the one feature of eating disorder psychopathology associated with the use of verbal control. Marital criticism was also associated with the extent of verbal controlling behaviour.
Conclusions Aspects of maternal control of infants were found to be specific to maternal eating disorder psychopathology.
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INTRODUCTION |
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Psychiatric disorder and parental controlling behaviour |
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Eating disorders and control |
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Specificity of parental controlling behaviour |
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Thus, the principal purposes of this study were (a) to examine in detail the influence of maternal eating disorder psychopathology on maternal controlling behaviour, (b) to establish whether the pattern of controlling was specific to eating disorders, and (c) to elucidate whether particular aspects of maternal mental state might be particularly important in influencing parenting control over young children.
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METHOD |
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Study 1 recruited 34 women with eating disorders during the postnatal year, of whom 18 fulfilled operational criteria for a DSMIIIR diagnosis of an eating disorder (American Psychiatric Association, 1987): 6 had bulimia nervosa, and 12 had an eating disorder not otherwise specified (EDNOS), of whom 4 had a history of bulimia nervosa. The remaining 16 women had sub-threshold conditions; 3 had a history of bulimia nervosa and 1 a history of EDNOS (see Stein et al, 1994 for more detail). Eight of the 13 women who fulfilled criteria for bulimia nervosa also had a history of anorexia nervosa. All of these mothers showed extreme concerns about body shape and weight of clinical severity during the first year of the child's life, and all manifested significant associated behavioural disturbance. Twenty-four healthy comparison mothers were selected from a community sample of young women, balanced for social class, maternal age and the child's gender. For the second study, 44 women were recruited with a primary DSMIIIR diagnosis of depressive disorder in the 6 weeks following childbirth, together with 42 healthy mothers without depression balanced for child gender, social class and maternal age (Badenoch, 1994). Thirty-nine cases and 37 comparison mothers were reassessed at follow-up when their children were 1 year of age. Two families had declined to participate further, two did not complete all the assessments, and six had moved out of the region. Thus, the overall sample across both studies comprised 34 mothers with an eating disorder, 39 mothers who had experienced postnatal depression and 61 healthy comparison mothers, together with their children.
All the assessments were conducted in the family home when the infants were aged 12-14 months. A number of visits were made. At the initial visit the study was explained to the families, and then a second visit was made to the family home to familiarise the mothers and children with the observational procedures. Three subsequent assessment visits were made.
Measures
Mother's mental state and marital relationship
The women were interviewed using the Eating Disorder Examination
(Fairburn & Cooper, 1993).
This standardised investigator-based interview assesses in detail the full
range of the characteristic psychopathology of eating disorders. It measures
the key behavioural and attitudinal features, including overeating, dieting,
self-induced vomiting, laxative misuse, and concerns about eating, shape and
weight. In order to assess other aspects of the mother's mental state, the
Symptom Check List (SCL) was administered, a self-report measure of general
psychiatric symptoms (Derogatis et
al, 1973). The level of perceived marital criticism was
measured using a scale devised by Hooley & Teasdale
(1989). This aspect of the
marital relationship was selected because it is most likely to reflect
controlling issues and because the scale has been shown to have predictive
validity in research with subjects with psychiatric disorders
(Hooley & Teasdale,
1989).
Observations of mother and child
The children were observed and videotaped in two situations at play
and at a mealtime using a modification of the procedure described by
Skuse et al (1992)
and within 3 weeks of the maternal mental state interviews. The play session
consisted of five 2.5-minute consecutive sessions of structured play; in the
first two sessions the mother was handed a toy and asked to play with the
infant using the toy in any way that she liked. During the final three
sessions the mother was given three toys, each in turn, and asked whether she
would show the infant how the particular toy worked; it was explained that
this was not a test. The general aim was to examine the way in which the
mothers helped their children and the extent of their mutual cooperation,
enjoyment and conflict. The last three tasks were designed to be a little too
difficult for children of 12-14 months, as we wanted to observe how the mother
responded to such a situation and, particularly, how she helped the child
enjoy the toys while maintaining the child's attention and interest. The
second videotaped situation was the main meal of the day. No other family
member was present in either situation.
Coding of videotapes
The videotapes were rated by a researcher who was blind to the mother's
group membership. The first involved event sampling, in which a specified
event/ behaviour was predefined, and each event was then counted and expressed
as a rate per hour. The second method involved time sampling, in which
particular behaviours were rated on predefined scales, every 2.5 minutes in
the case of play and every 2 minutes in the case of the mealtime. The areas
assessed were chosen on the basis of pilot work and on hypotheses concerning
the processes likely to mediate between the mother's psychiatric disorder and
potential disturbances in motherchild interaction and child
development. The observational procedures were based in part on instruments
developed by Skuse and colleagues (Wolke
et al, 1990; Skuse
et al, 1992) and Hinde
(Hinde et al, 1992).
Only items for which satisfactory reliability were obtained were included
(i.e. where kappa values were greater than 0.70 or raw percentage agreements
were greater than 75%, for time-sampled or event-sampled ratings
respectively).
Ratings
The following ratings were made:
For time-sampled ratings, the interrater reliability ranged from
0.74 to 0.91. The event-sampled behaviours occurred sporadically and therefore
raw percentage agreements were calculated, their range being 78-93%.
Data analysis
The distributions of each of the outcome variables were examined and those
that were not normally distributed were transformed by logarithms.
Given that the key question was whether the three groups of mothers differed in their controlling behaviour and in their pattern of control across play and mealtimes (and as each variable was measured in an identical way across both situations), a repeated measures analysis of variance was performed with the situation providing the repeated measures aspect. Thus, the three groups were compared across the two situations (play and mealtimes); if a significant difference was found, post hoc pairwise comparisons were performed to establish where the differences lay.
The next question was whether particular aspects of the mother's mental state influenced parental controlling behaviour. Thus a number of variables were added to the repeated measures analysis of variance. These included maternal eating concern, shape concern and dietary restraint (taken from the Eating Disorder Examination), depression (sub-scale taken from the SCL), as well as perceived marital criticism and the child's gender.
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RESULTS |
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Table 2 provides a summary of the maternal eating disorder psychopathology and depression scores and those of perceived marital criticism. There were significant between-group differences in the global Eating Disorder Examination scores (F= 9.81, P < 0.001), with the eating disorder group scoring significantly higher than both the postnatal depression group and the healthy comparison group. As far as the depression scores were concerned, there were significant between-group differences (F=12.79, P < 0.001), with both the postnatal depression group and the eating disorder group scores being significantly higher than the comparison group. The postnatal depression group scores were higher than the eating disorder group scores, but this was not statistically significant, indicating significant depressive symptomatology in the eating disorder group. There were no group differences in terms of perceived marital criticism.
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The results of the repeated measures analysis of variance are presented in Table 3. Although some of the variables needed to be transformed for the analysis, raw means and standard deviations are presented in order to facilitate inspection of the actual values of each variable for each group. A number of additional columns represent: between-subject (group) differences, i.e. comparison across three groups; interactions between group and situation; and post hoc pairwise comparisons which were performed when significant differences between groups were found in order to establish where specific differences existed between two groups.
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As can be seen from Table 3, between-group differences were found on a number of variables. There were significant differences in strong verbal control (F=7.74, P < 0.01) with post hoc pairwise comparisons showing that the mothers with eating disorders scored higher than the postnatal depression group and the comparison group, although there were no significant differences between the depression and comparison groups. In addition, there was a significant group x situation interaction effect, indicating that the pattern of differences between the groups differed across play and mealtime (F=3.35, P < 0.05). It seems that this interaction was due to the especially high levels of strong verbal control expressed by the mothers with eating disorders during play compared with the other two groups.
There was no significant difference between the groups on gentle verbal control. On the composite measure of controlling behaviour, the ratio of verbal control (gentle and strong) to all speech (controlling and non-controlling statements), there was a trend for a between-group difference (F=2.70, P=0.07), and the post hoc pairwise comparison indicated that the eating disorder group scored significantly higher than the normal healthy comparison group. There was also a significant group x situation interaction which, from inspection of the means, again appeared to be due to the high levels of verbal control exercised by the eating disorder group during play. In contrast, the mealtime scores of the three groups were very similar.
Mothers scored higher during play compared with mealtimes on all the
measures of controlling behaviour. Thus, all within-subject (play .
mealtime) comparisons were significant, e.g. strong verbal control
(F=172.65, P < 0.001 not in the table). The most
likely explanation for these findings is that they reflect the nature of the
structured play task which, as noted earlier, required mothers to show their
infants how a particular toy worked. The toys were selected because they were
slightly too difficult for children aged 12-14 months. This resulted in the
mothers in all groups using a variety of controlling strategies.
Finally, where variables were found to have significant between-group and/or group x situation interactions, the following covariates were added: body shape concern, eating concern, dietary restraint, depression, marital criticism and child gender. When these covariates were added to the repeated measures analysis of variance for strong verbal control, dietary restraint was found to be significant (F=4.79, P < 0.05). The group variable, however, remained significant (F=4.78, P=0.01), indicating that the original between-group effect held. When the covariates were added to the repeated measures analysis of variance for the percentage of verbal controlling to total statement variable, dietary restraint was again found to be a significant predictor of the outcome variable (F=7.35, P < 0.01). Marital criticism was also found to be a predictor of this variable (F=3.84, P=0.05). The group variable was no longer significant (F=1.1).
In order to examine whether the differences between the eating disorder group and the postnatal depression group might be accounted for by systematic differences between the samples recruited from the two geographical areas, further analyses were undertaken. The comparison groups were split into those recruited from the two sites, and were then compared on the variables that were found to distinguish the eating disorder and postnatal depression groups. No statistically significant differences were found. For example, on the composite variable measuring percentage of maternal controlling statements to total statements, F was 0.04 (not significant).
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DISCUSSION |
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Strengths and limitations
The study has a number of strengths; in particular, careful observations
were made of mothers and babies interacting on two separate occasions in two
different situations in a naturalistic setting (family home). Detailed
assessments were made of the mothers' verbal and non-verbal controlling
behaviour and the ratings were made blind to maternal mental state.
Furthermore, it is important to the interpretation of the findings that two
psychopathological groups were studied.
This study also has a number of limitations: in particular its cross-sectional nature limits the identification of causal processes, and the sample sizes were relatively small. In addition, no direct evidence of other influences on the mothers' controlling behaviour was obtained; in particular the fathers were not seen, although an assessment of the perceived marital criticism was made.
Furthermore, the study used data from two interrelated investigations based in two sites. Using data in this way can lead to difficulties in that there are potentially systematic differences between the two sites that could account for the findings. A number of steps were taken to minimise this problem, in that the subjects on the two sites were recruited from areas with a similar social class structure and the background characteristics of the sample were comparable in terms of social class and maternal age. Furthermore, the motherchild assessment procedures were identical and the videotapes were rated blind by the same rater using the same rating scales. In addition, analyses were undertaken to examine whether the differences between the eating disorder and the postnatal depression group, in terms of maternal parenting style, could be accounted for by differences between the sites. Thus, the healthy comparison subjects recruited from each site were compared on the variables that were found to distinguish the groups. No statistically significant differences were found. None the less, caution should still be exercised in interpreting the findings.
Control issues
The central findings of the study were that, when interacting with their
infants, mothers with eating disorders used more controlling (especially
strong controlling) speech than either of the other two groups; and that
mothers' own level of dietary restraint was particularly associated with such
controlling behaviour. As dietary restraint is a prominent feature of most
eating disorders, and is the element of eating disorder psychopathology that
is hypothesised to be the direct expression of the person's need for
self-control, the findings of this study suggest that the mothers' need to
control themselves extended to exerting control in the parenting domain. Thus,
mothers who exert strong control over their food intake and thereby their body
weight and shape may be at risk of being especially controlling of their
infants, hence providing support for the thesis that control is a central
psychopathological feature of eating disorders. While the hypothesis put
forward by Fairburn et al
(1999) concerned anorexia
nervosa, it is likely to apply to other eating disorders as well.
Control during play
The finding that the mothers with eating disorders were particularly
controlling of their infants during play is also of interest. It suggests that
their need for control goes beyond mealtimes and may be stronger in other
areas. It may be that, as a group, the mothers with eating disorders are
particularly liable to resort to controlling strategies when they perceive
themselves to be put under pressure, as occurred during the structured play
tasks.
Postnatal depression
It is of note that the mothers who had experienced a postnatal depression
were no different from the healthy comparison group in terms of controlling
behaviour. The lack of difference, in terms of verbal controlling behaviour,
between the depression and comparison groups is somewhat at variance with the
findings of some other studies in the field, which suggest that mothers with
depression may be more critical and controlling of their infants
(Murray et al, 1993).
However, depression is not a stable or uniform state. It is characterised on
the one hand by withdrawal and on the other by hostility, and both these
symptoms may be present in the same person at different times. It may be that
this variability in mental state accounts for our findings, as suggested by
some of the work of Cohn et al
(1986). It should also be noted
that this study focused particularly on one aspect of parenting behaviour and
that there is good evidence from several other studies that postnatal
depression interferes with a number of other important parenting domains
(Murray & Cooper,
1997).
In conclusion, the focus of this study was deliberately narrow to examine whether maternal psychopathology is related to parental controlling behaviour. It was found that particular features of parental psychopathology, specifically dietary restraint, are most likely to have an impact on this aspect of parenting. Given the importance of the capacity for negotiation and the need for parents to appreciate the infant's perspective, these findings may have important clinical implications. Parents with eating disorders may need help in attending to their infant's cues and in modulating their intervention and interactions with their infants. Given that these controlling patterns of parental interaction are evident so early in the child's life, prevention and early intervention should be a priority with health care planners and clinicians.
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Clinical Implications and Limitations |
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LIMITATIONS
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ACKNOWLEDGMENTS |
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REFERENCES |
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Received for publication July 3, 2000. Revision received August 2, 2000. Accepted for publication August 8, 2000.
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