Leopold Muller Centre for Child and Family Mental Health, and The Tavistock Clinic, London
Institute for the Study of Children, Families and Social Issues, University of London
Primary Care and Populations Sciences, Royal Free and University College Medical School, London
Unit of Paediatric and Perinatal Epidemiology, Institute of Child Health, University of Bristol, Bristol, UK
on behalf of the ALSPAC Study Team
Correspondence: Dr R. Senior, Leopold Muller Centre for Child and Family Mental Health, Rowland Hill Street, London NW3 2PF, UK. E-mail: rsenior{at}tavi-port.nhs.uk
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ABSTRACT |
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Aims This study was designed to explore which early experiences, recalled during pregnancy, were associated with both lifetime and antenatal eating disorder symptoms in a community sample.
Method Univariate and multivariate analyses were conducted of data from questionnaires administered during pregnancy to a community sample of pregnant women.
Results Recall of parental mental health problems and of early unwanted sexual experiences were independently associated with both lifetime eating problems, laxative use and vomiting during pregnancy, and marked concern during pregnancy over shape and weight.
Conclusions There are public health implications for these results. Eating disorders in mothers represent a risk for child development. It may be important to enquire during pregnancy about a history of eating problems and to provide the opportunity for early experiences to be discussed.
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INTRODUCTION |
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An aetiological link has been proposed between sexual abuse and eating disorders (Waller, 1992; Welch & Fairburn, 1994). In a comprehensive review of the relationship between sexual abuse and bulimia nervosa, Pope & Hudson (1992) concluded that controlled studies did not generally find a significantly higher prevalence of childhood sexual abuse for patients with bulimia compared with control groups. Welch & Fairburn (1994) determined the prevalence rates of reported sexual abuse in women with bulimia nervosa identified from a community sample and in a referred clinical sample. Comparing these women with a psychiatric control population and a matched control group without psychiatric problems, a history of sexual abuse involving physical contact and a history of repeated sexual abuse were both significantly more common among the community group with bulimia nervosa than among the comparison group without psychiatric problems. Since a history of abuse was just as common for the psychiatric comparison group, these authors concluded that although sexual abuse was a risk factor for the development of bulimia nervosa, it did not appear to be specific to this disorder. Other authors (Everill & Waller, 1995) have argued for a more complex relationship between eating disordered psychopathology and a history of abuse, with considerable variation in sequelae depending on the nature and circumstances of the abuse and individual vulnerability or resilience.
Recent life events appear to trigger bulimia nervosa (Welch et al, 1997) and anorexia nervosa (Schmidt et al, 1997), but less is known about the role of disruptive life events occurring in childhood in contributing to the later appearance of eating disorders. Regarding early experiences of parenting, Vandereycken (2002) pointed out the shortcomings involved in relying on the retrospective recall of patients with psychological problems. He concluded that patients with bulimia nervosa tend to report more troubled childhood experiences than patients with anorexia or control groups without psychiatric problems, and recall their rearing in childhood as characterised by a lack of care, especially by their mothers. However, Romans et al (2001) in an epidemiological study identified early menarche and paternal over-control as risk factors for eating disorders in women who reported experiencing child sexual abuse.
Eating disorder symptoms are not uncommon in women of childbearing age, with up to 4% of women affected if those with extreme concerns about body shape and weight and disrupted eating patterns are included with those meeting the criteria for anorexia or bulimia nervosa (Hoek, 1993). Pregnancy itself has an inevitable and complex impact on attitudes to weight and shape and on eating disorder symptoms. For many women, pregnancy is the first time they have experienced major body changes since early adolescence. There is evidence from a number of studies that pregnant women are generally accepting of their larger body size and make few attempts to control it (Davies & Wardle, 1994). However, in clinical samples of women with eating disorders, many expressed negative feelings about the weight gain and changes in body shape during pregnancy (Fairburn & Welch, 1990).
Many of the studies cited above were small samples and/or based on clinical populations. Our study is based on a large, community sample. It was designed to explore which early experiences, recalled during pregnancy, were associated with both lifetime and antenatal eating disorder symptoms. Our hypothesis was that women recalling adverse parenting experiences and those recalling early sexual abuse would have more eating disorder symptoms, both lifetime and antenatally.
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METHOD |
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Measures
Three postal questionnaires administered during pregnancy provided the data
for this paper: Having a Baby, sent at 18 weeks gestation,
Your Pregnancy, at 32 weeks gestation, and About
Yourself, which could be completed at any time during pregnancy.
Explanatory variables
Parental mental health and family life
The About Yourself questionnaire contained items on mental health
problems (schizophrenia, depression, alcohol misuse) of the respondents
parents (both natural and non-biological); loss of a parent, or separation
from them; early recall of family life as happy or not (defined by a
five-point scale) at three ages (05 years, 611 years and
1215 years) and whether each parent was stable and predictable.
Questions in Your Pregnancy asked whether either parent was
physically or emotionally cruel and whether parents had divorced or separated.
In addition, respondents completed the Parental Bonding Instrument
(Parker et al, 1979)
about experiences up to the age of 16 years with each parent, from which two
scores are derived: parental over-protection and parental control.
Early sexual abuse
Your Pregnancy included one question under your
childhood about sexual abuse (Did it occur? yes/no), and
then at its conclusion a detailed section of questions about early sexual
experiences - early defined as occurring before the age of 16
years. It was noted that some respondents might not wish to answer and that
they could leave these items blank if desired. Questions covered a number of
sexual acts (further details are available from the authors upon request), who
had been involved, the age at which each act occurred and whether the act was
wanted or not. A coding (binary yes/no) of early sexual abuse was given if the
woman reported experiencing any unwanted sexual contact before the age of 16
years, excluding non-contact indecent exposure (flashing) but
including an abuser masturbating in front of them. Excluding non-contact
flashing created a variable that correlated more strongly with
abuse according to the binary question Did abuse occur?.
Demographic factors and current circumstances
About Yourself included questions on a number of demographic and
current factors, including social class, ethnic origin, age at completion of
the questionnaires, social networks and social support (the social support
scale developed was specifically for ALSPAC).
Outcomes
Lifetime and pregnancy eating disorder symptoms
About Yourself contained questions about a lifetime history of
anorexia nervosa and bulimia (yes/no). Having a Baby asked about
self-induced vomiting and laxative use for weight loss. A lifetime eating
disorder symptoms score was derived by including a positive response to any of
these four questions. Your Pregnancy included questions about the use
of laxatives and vomiting to lose weight during pregnancy.
Eating disorder symptoms, marked shape and weight concern
The Your Pregnancy questionnaire included selected items from the
Eating Disorder Examination Questionnaire (EDEQ;
Fairburn & Beglin, 1994),
covering eating and weight concerns in the previous 28 days, and prior to the
pregnancy. Included were five of the nine items comprised by the EDEQ
Shape Concern sub-scale and five of the six EDEQ Weight Concern items.
In a sample of women already identified as having eating problems
(Stein et al, 1995),
it was established that scores from the reduced sub-scales correlated
significantly with the full sub-scale scores (weight 0.99, shape 0.98). Each
item has a three-point scale and each sub-scale score is the mean of five
items (minimum 1.0, maximum 3.0). Based on the distribution of scores, a
cut-off point of 2.0 or more was selected to indicate marked shape or weight
concern.
Statistical analysis
The aim of the analysis was to examine the influence of early experiences
on eating disorder symptoms. Univariate analyses were conducted to identify
potential relationships between risk factors and outcomes. Chi-squared tests
were used for categorical variables and t-tests for continuous
variables. For each outcome, odds ratios are presented for mothers with the
risk factor relative to mothers without that particular risk factor. However,
many of the explanatory variables are interrelated. In order to examine which
factors had an independent influence on eating problems, multivariate analyses
were conducted using logistic regression programmes from SAS version 8.2,
suitable for estimating influences on binary outcome variables. Multiple
logistic regression, including the factors significant in univariate analyses,
was used to examine which risk factors had independent effects on eating
problems. Of the 10 641 women included in the analysis, complete risk factor
data were available for 7806 women, owing partly to the lower response rate
(90%) to the detailed sexual abuse questionnaire. The univariate analyses
reflect the numbers of women who gave complete information for each relevant
item, and the multivariate regression analyses include only women who gave
complete information on all relevant items. Best subset models were chosen by
backwards elimination and through testing the increases in deviance against a
2 distribution. All variables in final models met the 5% level
of significance (see Table 1
for predictors entered into models). All P values are two-sided.
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RESULTS |
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Predictors of eating disorder symptoms
Lifetime eating disorder symptoms
A number of early experiences significantly predicted lifetime eating
disorder symptoms (Table 2).
They included recall of parental alcohol misuse, depression or other mental
health problems. However, the highest odds ratios were for parental cruelty
(physical, OR=2.53; emotional, OR=2.12) and experience of sexual abuse
(OR=2.16). Conversely, happy memories throughout childhood and recall that
parents were stable most of the time were associated with a lower rate of
eating disorder symptoms. Parental death and low social class were not related
to lifetime eating disorder symptoms. Multivariate analysis indicated that
there was an independent effect of parental depression, alcohol problems and
recall that childhood was not happy (Table
3). However, the most predictive variable (in terms of its
contribution to the 2 likelihood ratio statistic in the fully
adjusted model) was sexual abuse.
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Antenatal eating disorder symptoms
Eating disorder symptoms (self-induced vomiting, laxative use to lose
weight) during pregnancy were predicted by a similar set of early experiences,
including parents with alcohol problems or depression, parents being
emotionally or physically cruel, and having been sexually abused (see
Table 2). Again, those
recalling a happy childhood were significantly less likely to report eating
disorder symptoms during pregnancy. The death of a parent was not a
significant factor. However, based on multiple regression, fewer factors were
relevant. Those independently associated with self-induced vomiting or
laxative use in pregnancy were having a parent (in most cases the mother) with
depression (OR=1.47, 95% CI 1.062.04) and more early life events (for
top group relative to bottom group OR=1.96, 95% CI 1.213.17). Being of
White ethnic origin and having a high social support score were associated
with a reduced likelihood: OR=0.31 (95% CI 0.170.56) and 0.80 per
standard deviation increase (95% CI 0.690.92), respectively.
Marked shape and weight concern during pregnancy
Recall of parental alcohol or mental health problems, parental depression
or death, parental cruelty, parental divorce and early sexual abuse were all
significant univariate predictors of marked concern over shape and weight
during pregnancy, whereas recall of a happy childhood and stable parental
behaviour were again predictive of less concern
(Table 4).
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Taking other factors into account, there remained a significant relationship between sexual abuse and concern over shape and weight, but this was not the case for parental mental illness or cruelty (Table 5). Women who reported highly over-protective parenting were more likely to have marked concern over their shape and weight, whereas those reporting a happy childhood or high social support scores were less likely to have such concerns.
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DISCUSSION |
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Limitations of the study
Although our study demonstrates that sexual abuse is associated with eating
disorder symptoms, independently of a number of well-established factors such
as parental alcohol misuse or depression and physical or emotional cruelty, it
does not address the question of whether early sexual abuse has a causal
relationship with the subsequent development of eating difficulties or of
other psychiatric problems. Some eating difficulties might have preceded the
abusive experiences. In addition, although the life-time eating disorder
symptoms score was derived by asking about a history of anorexia nervosa and
bulimia or of self-induced vomiting and laxative use for weight loss, it does
not indicate a diagnosis of eating disorder. Similarly, the modified
EDEQ for eating disorder symptoms in pregnancy is not a diagnostic
instrument. Any specific risk for eating disorder rather than eating disorder
symptoms is not explored in this study.
This study relies on retrospective recall of early family life, eating disorder symptoms and unwanted sexual experiences. The problems associated with retrospective recall of child sexual abuse are well known, and include forgotten or non-disclosed abuse and the reporting and possible construction of abusive experiences to make sense of current distress. It is not clear what bias in recall, if any, is attributable to pregnancy. The precise nature of the sexual abuse, the age at which it occurred, whether it was repeated, whether the child was believed and other important mediators and modifiers of the effect of the abuse are not considered. Other potentially important parental contributions, including genetic ones, to the development of eating disorder symptoms have not been considered. Further, this study cannot answer the question about whether there is a specific association between early sexual abuse and eating problems, taking into account other types of symptom (e.g. depression, anxiety).
Public health and clinical implications
Maternal eating problems in the postnatal period have been shown to pose a
particular risk to the developing child by interfering with parenting and
child growth (Stein, et al,
1994). Thus there are substantial public health implications of
addressing early experiences that might be related to weight and shape
concern. It has already been established in this same community sample that
women with excessive concerns about shape and weight are less likely to plan
breast-feeding (Barnes et al,
1997). This suggests that preventive interventions that allow
discussion about the impact of early experiences might be an important route
for prevention.
Health professionals dealing with pregnant women need to be aware of the high prevalence of eating disorder symptoms and the possible association in some women with a history of adverse experiences in childhood. The majority of women with concerns about weight, shape and eating do not describe a history of abuse and professionals may have reservations about raising the topic, but it may be important to do so with some women, in the context of a supportive relationship with a midwife, health visitor or general practitioner during pregnancy.
Implications for future research
Prospective longitudinal studies are indicated to explore these
associations further. Such studies would need to include large numbers and
attempt to validate reported abusive experiences and other early influences
through interviews and by other means. Interventions designed to improve the
outcome for mothers and their children by addressing womens eating
disorder symptoms with or without attention to their history, where present,
of adverse experiences, will need to be tested.
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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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Davies, K. & Wardle, J. (1994) Body image and dieting in pregnancy. Journal of Psychosomatic Research, 38, 787 -799.[CrossRef][Medline]
Everill, J. & Waller, G. (1995) Reported sexual abuse and eating psychopathology: a review of the evidence for a causal link. International Journal of Eating Disorders, 18, 1-11.[Medline]
Fairburn, C. & Beglin, S. (1994) Assessment of eating disorders: interview or self-report questionnaire? International Journal of Eating Disorders, 16, 363 -370.[Medline]
Fairburn, C. & Welch, S. (1990) The impact of pregnancy on eating habits and attitudes to shape and weight. International Journal of Eating Disorders, 9, 153-160.
Fairburn, C., Welch, S., Doll, H., et al (1997) Risk factors for bulimia nervosa. Archives of General Psychiatry, 54, 509 -517.[Abstract]
Fairburn, C., Cooper, Z., Doll, H., et al
(1999) Risk factors for anorexia nervosa. Archives
of General Psychiatry, 56, 468
-476.
Halmi, K. A. (1995) Current concepts and definitions. In Handbook of Eating Disorders: Theory, Treatment and Research (eds G. Szmuckler, C. Dare & J. Treasure), pp. 29 -42. Chichester: John Wiley.
Hoek, H. (1993) Review of the epidemiological studies of eating disorders. International Review of Psychiatry, 15, 346 -348.
Parker, G., Tupling, H. & Brown, L. B. (1979) A parental bonding instrument. British Journal of Medical Psychology, 52, 1 -10.
Patton, G. C., Selzer, R., Coffey, C., et al
(1999) Onset of adolescent eating disorders: population based
cohort study over 3 years. BMJ,
318, 765
-768.
Pope, H. & Hudson, J. (1992) Is childhood sexual abuse a risk factor for bulimia nervosa? American Journal of Psychiatry, 149, 455 -463.[Abstract]
Romans, S., Gendall, K., Martin, J., et al (2001) Childhood sexual abuse and later disordered eating: a New Zealand epidemiological study. International Journal of Eating Disorders, 29, 380 -392.[CrossRef][Medline]
Schmidt, U. (2002) Risk factors for eating disorders. In Eating Disorders and Obesity (2nd edn) (eds C. Fairburn & K. Brownell), pp. 247-250. London: Guilford.
Schmidt, U., Tiller, J., Blanchard, M., et al (1997) Is there a specific trauma precipitating anorexia nervosa? Psychological Medicine, 27, 523 -530.[CrossRef][Medline]
Spataro, J., Mullen, P. E., Burgess, P. M., et al
(2004) Impact of child sexual abuse on mental health:
Prospective study in males and females. British Journal of
Psychiatry, 184, 416
-421.
Stein, A., Woolley, H., Cooper, S. D., et al (1994) An observational study of mothers with eating disorders and their infants. Journal of Child Psychology and Psychiatry, 35, 733 -748.[Medline]
Stein, A., Stein, J., Walters, E., et al
(1995) Eating habits and attitudes amongst mothers of
children with feeding disorders. BMJ,
310, 228.
Vandereycken, W. (2002) Families of patients with eating disorders. In Eating Disorders and Obesity (2nd edn) (eds C. Fairburn & K. Brownell), pp. 215 -220. London: Guilford.
Waller, G. (1992) Sexual abuse and bulimic symptoms in eating disorders: do family interaction and self-esteem explain the links? International Journal of Eating Disorders, 12, 363 -370.
Welch, S. & Fairburn, C. (1994) Sexual abuse and bulimia nervosa: three integrated case control comparisons. American Journal of Psychiatry, 151, 402 -407.[Abstract]
Welch, S., Doll, H. & Fairburn, C. (1997) Life events and the onset of bulimia nervosa: a controlled study. Psychological Medicine, 27, 515 -522.[CrossRef][Medline]
Received for publication May 24, 2004. Revision received November 1, 2004. Accepted for publication November 5, 2004.
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