North Bristol NHS Trust, Southmead Hospital, Bristol
University of Liverpool, Liverpool
![]() |
![]() ![]() ![]() ![]() ![]() ![]() ![]() ![]() ![]() |
---|
Correspondence: Dr P. Shoebridge, Consultant Child, Adolescent and Family Psychiatrist, Southmead Hospital, Westbury-on-Trym, Bristol BS10 5NB
![]() |
ABSTRACT |
---|
![]() ![]() ![]() ![]() ![]() ![]() ![]() ![]() ![]() |
---|
Aims To look for evidence of parental high concern occurring before any onset of disorder.
Method Forty consecutive referrals of adolescent girls with DSM-III-R anorexia nervosa were compared with matched controls using obstetric records and maternal interviews.
Results Index mothers reported higher rates of: near-exclusive child care (P=0.02), infant sleep difficulties (P=0.018), severe distress at first regular separation (P=0.048), high maternal trait anxiety levels (P=0.008) and later age for first sleeping away from home (P=0.009). More index families had experienced a severe obstetric loss prior to their daughter's birth (P=0.066).
Conclusions This study lends evidence to the clinical contention that high-concern parenting in infancy is associated with the later development of anorexia nervosa. This may derive, in part, from aspects of unresolved grief.
![]() |
INTRODUCTION |
---|
![]() ![]() ![]() ![]() ![]() ![]() ![]() ![]() ![]() |
---|
![]() |
METHOD |
---|
![]() ![]() ![]() ![]() ![]() ![]() ![]() ![]() ![]() |
---|
Matching with normal controls was achieved individually by pairing for age, gender, ethnicity and maternal-child age difference using a large general practitioner (GP) age/gender register. The GP practice was selected to approximately match the occupational grouping profile found in the anorectic group (Market Research Society, 1991). Exclusion criteria included any lifetime child psychiatric diagnosis, and having scores on the Eating Attitudes Test-26 (EAT-26; Garner et al, 1982) of more than 17 (Wood et al, 1992).
Sources of data
Maternal obstetric record
The obstetric notes of cases and controls were obtained and photocopies of
the records were made. All references to the subject's name were masked,
enabling these to be scored blind. These records were then rated for details
of the mother's previous obstetric history and the subject's pregnancy.
Categorical scoring systems were developed for qualitative variables. Previous
obstetric histories were recorded using standard definitions of miscarriage,
stillbirths and early neonatal, neonatal, perinatal and infant deaths
(Forfar, 1984). References to
previous complicated deliveries or births of children with severe birth
defects were also noted.
Maternal structured clinical interview covering the subject's
pregnancy, early infancy and childhood
This elicited information relating to: past obstetric history, including
fertility worries; marital difficulties in the two years before the birth of
their daughter and for the following five years; division of caring duties for
the baby/infant between their main carers; length of breast-feeding; maternal
postnatal depressive illness; infant feeding problems, focusing on severe
faddiness and behavioural difficulties at meal times
(Marchi & Cohen, 1990); duration of nursing the newborn in the parent's room; infant sleeping
difficulties, particularly coming into the parents' bed against the parents'
wishes; consulting child-care professionals in the first few months; worries
regarding developmental difficulties; perceived susceptibility to illness;
experience of life-threatening illnesses in the first five years; degree of
distress experienced by mothers and exhibited by their daughters when they
were left on a regular basis (child-minder, nursery or school); age when first
allowed to stay overnight away from home. Data were mainly recorded as
verbatim responses. Scoring systems were developed to enable blind categorical
ratings.
A maternal self-report anxiety questionnaire
The State-Trait Anxiety Inventory (STAI;
Spielberger, 1983), was
used.
Statistical analysis
Categorical data were analysed using Fisher's exact test or
2 comparisons between the two groups. Continuously distributed
data, such as the STAI scores, were compared using t-tests.
Statistical procedures were carried out either using the SPSS/PC software
package (version 5.0) or INSTAT2, employing two-tailed statistical tests.
![]() |
RESULTS |
---|
![]() ![]() ![]() ![]() ![]() ![]() ![]() ![]() ![]() |
---|
In addition to the excellent individual matching for the prospectively chosen demographic variables (see Table 1), we also found a number of other potentially important confounding variables that were almost perfectly matched: children's birth order; birth histories; parental marital status at the time of becoming pregnant; frequency and severity of marital difficulties both before and after the birth of the index subjects; and maternal puerperal smoking habits.
|
Data capture rates
We obtained medical archival information on 95% of the subjects with
anorexia nervosa (38/40) and 90% of the normal controls (36/40), one of these
relying on GP rather than complete hospital records. One set of the patients'
notes was reported lost and another proved unobtainable. In these instances
the maternal interview obstetric history data were used.
Semi-structured interview data were obtained on all subjects. Of the normal control subjects 97.5% (39/40) completed an EAT-26 (mean=3.03, s.d.=3.11, range=0-17). One control subject scored 17 and all others scored 10 or below.
Data from the obstetric and maternity case notes
Preconceptual factors
Five of the index cases and eight control case notes recorded a previous
first-trimester miscarriage. Fifteen per cent (6/40) of the index mothers had
experienced a perinatal or infant death prior to the birth of their child with
anorexia nervosa, compared with 2.5% (1/40) of their matched normal controls
(P=0.108). In total, 10 of the group with anorexia nervosa had
experienced a prior severe obstetric loss (25%) compared with three (7.5%) of
their matched controls (P=0.0661) (see
Table 2). In all but one of
these cases the subjects with anorexia nervosa were the next-born female
child.
|
The suggestion of unresolved loss is attested to by the verbatim reports of these mothers. Firstly, the quotes of the mothers with anorexia nervosa:
The corresponding comments from the three control mothers included:
Perinatal factors
Details of birth-related variables for the index subjects and their
controls are shown in Table 3.
There were no significant differences in either the obstetric management or
complication rates. The biggest numerical difference occurred in the frequency
of Caesarean sections, with the group with anorexia nervosa having four and
the control group having one. Three of these four subjects with anorexia
nervosa were cases in which the mothers had experienced still-births or early
neonatal deaths in their previous pregnancy.
|
The most notable group difference occurs in the numbers of subjects who were looked after in a SCBU. Again, four out of five of these cases of anorexia nervosa had previously experienced a perinatal death. It seems likely that parental and/or obstetric team anxieties played a part in this.
A larger number of mothers with anorexia nervosa recollected worrying significantly about miscarrying during their pregnancy (10/40 v. 2/40; P=0.028). Postnatal maternal depression revealed most index mothers admitting to depressive mood symptoms persisting longer than six months, although this difference did not reach statistical significance. Only one of these index mothers had previously experienced a severe obstetric loss.
Infancy and early childhood
Fifteen out of 40 (37.5%) index mothers estimated that they provided over
95% of the baby and infant care, to the almost virtual exclusion of their
fathers, compared with only 5/40 (12.5%) of the control mothers
(P=0.02). Infant sleep pattern difficulties were also significantly
over-represented in the group with anorexia nervosa (19/40 v. 8/40;
P=0.018). The index mothers reported experiencing more
moderate/severe distress themselves when leaving their daughters in nursery
for the first time (12/40 v. 4/40; P=0.048). Index mothers
reported that their daughters were significantly older when they first spent a
weekend in the care of other adults (P=0.009). Highly significant
differences were obtained for cut-offs of 11 and 15 years.
Other factors that were enquired about but showed no differences included: the length of time the child was breast-fed; any reported eating difficulties in the first five years; consulting outside professionals in the first two months; the period of time nursing their daughter in the same room as the parents at night; parental perceptions that their daughters needed more care and attention than other children; and the incidence of serious life-threatening illnesses.
Questionnaire results
A total of 97.5% (39/40) of the control and 100% of the index mothers
completed the STAI Questionnaire. The mothers scored significantly higher on
this measure (mean=40.93 and s.d.=10.63 v. mean=35.26 and s.d.=7.09;
P<0.008).
Overview of the evidence for high-concern parenting
In order to determine whether the multiple observed differences occur
because a small fraction of the index cases score positively on all
high-concern factors, we tabulated the sum total of factors for each subject.
The factors included were: severe obstetric losses; fertility worries;
significant puerperal worries about losing the pregnancy; near-exclusive
maternal child care in the first five years; severe child upset at first
regular separation; first weekend away from parents after 11 years of age; and
high maternal trait anxiety. Continuously distributed variables were taken to
be present if they scored above the control group mean plus one standard
deviation. Twenty-three (57.5%) of the index cases registered two or more
high-concern factors, compared with six (15%) of the control cases. The
difference in how these factors are distributed between the groups is attested
to by the 2 analysis with the test for trend
(P=0.0002; see Table
4).
|
![]() |
DISCUSSION |
---|
![]() ![]() ![]() ![]() ![]() ![]() ![]() ![]() ![]() |
---|
Many of the variables that we enquired about relate to dyadic anxiety surrounding separation, suggesting early insecure attachment patterns. The literature suggests that mothers with insecurely attached infants are more likely to have insecure attachment representations themselves (Fonagy et al, 1994) and this attachment classification is known to be linked with higher levels of anxiety disorders in mothers (Manassis et al, 1994).
We found no significant differences in parents' recollections of feeding difficulties in the infants' first five years. This contrasts with Marchi & Cohen's (1990) findings. Their prospectively obtained evidence for picky eating and digestive problems at their first interview (mean age six years) being associated with anorexic symptoms in adolescence (mean age 16 years) must be interpreted in the light of their random sample of over 800 children actually having no cases of anorexia with amenorrhoea. Their results may not apply to cases of anorexia nervosa as described here.
Maternal trait anxiety
Our findings of higher index maternal trait anxiety scores are of interest
in view of their consistent association with overprotective attitudes
(Parker, 1983). Maternal
stress or elevated prenatal Spielberger anxiety trait scores have been shown
to be associated with increased rates of emergency paediatric consultations in
the first years of the infant's life
(Goldman & Owen, 1994). In
this prospectively designed study, trait anxiety was the only statistically
significant factor to emerge in their regression analyses, with paternal
anxiety, obstetric complications, marital satisfaction and life event scores
showing no association. Such increased usage of paediatric services would
certainly be expected to reflect higher levels of parental concern. In the
present study four items targeting evidence of recollected parental concern
about their daughters' early physical and developmental health revealed no
group differences. Gestational age, birth weight and obstetric complications
were not associated with higher trait anxiety scores in this study.
The reported correlation between state and trait anxiety (Spielberger, 1983) invites the interpretation that mothers who have gone through the harrowing experience of their daughter's anorexia may well be made more trait anxious as a result. This might therefore represent the effect of the illness rather than a true premorbid maternal characteristic.
Worrying about the health of the unborn child is likely to be a direct manifestation of parental concern. This experience is likely to relate to both higher constitutional levels of anxiety as well as reflecting a cognitive set influenced by prior aversive experience. Six of the 10 mothers who reported moderate to severe worries about losing their child during pregnancy had STAI scores that were greater than one standard deviation above the group mean. Five had also experienced a severe obstetric loss.
Severe obstetric losses
In view of these relative methodological merits and deficiencies, the
finding of a high frequency of previous severe obstetric losses experienced by
the index parents prior to the birth of their daughters, although just below
the threshold for significance (P=0.066), is of interest. The
significance of this difference is increased by the observation that nine of
the 10 daughters in this subgroup were the next-born child after their
parent's tragic loss.
There is evidence from the paediatric literature that the child born immediately after a tragic loss may become the recipient of parental overprotective care (Levy, 1943). This phenomenon has been referred to as the vulnerable child syndrome (Green & Solnit, 1964) or the replacement child syndrome (Powell, 1995). One descriptive report has linked a subgroup of young children with anorexia nervosa specifically with the vulnerable child syndrome (Atkins & Silber, 1993). Early pregnancy following a stillbirth has been shown to be associated with increased rates of maternal depression and anxiety (Hughes et al, 1999).
It is notable that in Rastäm & Gillberg's (1992) population-based study of anorexia nervosa they report a higher than expected prevalence of deceased first-degree relatives in their sample of 52 community-detected cases. They found four cases of siblings who had died before the onset of anorexia nervosa, but no sibling deaths in their control group. They do not report any data regarding their subjects' mothers' previous obstetric histories. Both clinically and in the research literature (Kirkley-Best & Kellner, 1982), it is noted how perinatal losses and miscarriages are frequently under-reported, hence this figure may be an underestimate.
Differences in obstetric complications
In respect of our second hypothesis we found no evidence for an excess of
obstetric complications, prematurity, neonatal distress or smaller birth
weights in the births of our subjects with anorexia nervosa. This accords with
one population-based study
(Rastäm,
1992) but contrasts with one uncontrolled
(Morgan & Russell, 1975)
and one controlled study (Kay et
al, 1967). Our finding of a slight excess of cases looked
after in SCBUs (five anorectic cases compared to two controls) may be a
reflection of the maternal (and probably medical) anxiety relating to the
earlier loss of a viable child in four of these five anorectic cases.
Methodological merits of data sources
The medical case note data are likely to be the most robust data because
they are not susceptible to any form of systematic parental recall bias. The
semi-structured interview data are likely to be of intermediate reliability
and validity because they concentrate on the mother's recollections of her
pregnancy and the child's early infancy during a period clearly distinct from
any prodromal or active anorexic illness behaviour. Nevertheless,
reattributions and reinterpretations of these aspects of the premorbid family
environment may be made in an effort after meaning in the light
of the profound upset caused by their daughter's illness.
Methodological strengths and weaknesses
One of the methodological deficiencies of our study is that the maternal
interviews were not conducted blind to group membership. The method of
administering the interview, with its structured format and standardised
manner of asking questions and recording answers, should limit tendencies for
bias by the interviewer, although this possibility cannot be excluded. The
procedure of anonymising the subject interviews prior to a research colleague
quantifying the qualitative aspects of the interviewees' responses did permit
single-blind ratings of many of the variables from this data source.
A further limitation in common with much previous research in this area is the modest size of the sample, increasing the likelihood of Type I error. In addition, despite opting for more conservative statistical tests (using group rather than pairwise matching), we have not employed Bonferroni's correction in view of the large number of comparisons made. While making these points, it is worth drawing attention to the fact that the sample sizes in this study are relatively substantial when viewed in the context of previous similar research. Being a rare disorder, accumulating large, diagnostically pure samples of subjects with anorexia nervosa requires multicentre collaboration or substantial recruitment periods (Shaw & Garfinkel, 1990). Indeed, the implication of this study finding statistically significant differences in such relatively small sample sizes, taken together with the multiple trends that occurred in the anticipated direction, suggests that parental high concern may have a substantial effect size as a factor contributing to the aetiology of anorexia nervosa. It is also relevant that we found such a variety of significant group differences, despite the close matching of the study and control groups, because overmatching can reduce the variability between the samples of the factor(s) of primary interest (Schlesselman, 1982).
Among the strengths of the study are the low refusal rates, a consecutive sample of cases of anorexia nervosa, the wellmatched samples, the high percentage of case notes that were traced and the combination of convergent strategies, all of which separately give evidence supporting the central hypotheses. The inclusion of some qualitative data about the parents' recollections of their losses may be seen as enriching the data.
This sample of girls with anorexia nervosa was recruited from a regional referral centre, which might attract a relatively severely affected clinical group. Hence, conclusions derived from these findings may not be safely generalised to adolescents presenting with less serious disorders.
![]() |
Clinical implications and Limitations |
---|
![]() ![]() ![]() ![]() ![]() ![]() ![]() ![]() ![]() |
---|
LIMITATIONS
![]() |
REFERENCES |
---|
![]() ![]() ![]() ![]() ![]() ![]() ![]() ![]() ![]() |
---|
Apgar, V. (1953) A proposal for a new method of evaluation of the newborn infant. Current Researches in Anesthesia and Analgesia, 32, 260-267.
Atkins, D. M. & Silber, T. J. (1993) Clinical spectrum of anorexia nervosa in children. Journal of Developmental and Behavioural Pediatrics, 14, 211-216.
Fonagy, P., Steele, M., Steele, H., et al (1994) The theory and practice of resilience. Journal of Child Psychology and Psychiatry, 35, 231-257.
Forfar, J. O. (1984) Demography, vital statistics and the patterns of disease in childhood. In Textbook of Paediatrics (eds J. O. Farfar & G. C. R. O'Neil). Edinburgh: Churchill Livingstone.
Garner, D. M., Olmstead, M. P., Bohr, Y., et al (1982) The Eating Attitudes Test: psychometric features and clinical correlates. Psychological Medicine, 12, 871-878.[Medline]
Goldman, S. L. & Owen, M. T. (1994) The impact of parental trait anxiety on the utilisation of health care services in infancy: a prospective study. Journal of Paediatric Psychology, 19, 369-381.
Green, M. & Solnit, A. J. (1964) Reactions to the threatened loss of a child: a vulnerable child syndrome. Pediatrics, 34, 58-66.[Abstract]
Hughes, P. M., Turton, P. & Evans, C. D. H.
(1999) Stillbirth as a risk factor for depression and anxiety
in the next pregnancy: cohort study. British Medical
Journal, 318,
1721-1724.
Kay, D. W. K., Schapira, K. & Brandon, S. (1967) Early factors in anorexia nervosa compared to non-anorexia groups. Journal of Psychosomatic Research, 11, 133-139.[CrossRef][Medline]
Kirkley-Best, E. & Kellner, K. (1982) The forgotten grief: a review of the psychology of still birth. American Journal of Orthopsychiatry, 52, 420-429.[Medline]
Levy, D. M. (1943) Maternal Overprotection. Columbia: Columbia University Press.
Manassis, K., Bradley, S., Goldberg, S., et al (1994) Attachment in mothers with anxiety disorders and their children. Journal of the American Academy of Child and Adolescent Psychiatry, 33, 1106-1113.[Medline]
Marchi, M. & Cohen, P. (1990) Early childhood eating behaviours and adolescent eating disorders. Journal of the American Academy of Child and Adolescent Psychiatry, 29, 112-117.[Medline]
Market Research Society (1991) Occupational Groups: a Job Dictionary (3rd edn). London: Market Research Society.
Morgan, H. G. & Russell, G. F. M. (1975) Value of family background and clinical features as predictors of long-term outcome in anorexia nervosa: four-year follow-up study of 41 patients. Psychological Medicine, 5, 355-371.[Medline]
Parker, G. (1983) Parental Overprotection. A Risk factor in Psychosocial Development. Sydney: Grune & Stratton.
Powell, M. (1995) Sudden infant death syndrome: the subsequent child. British Journal of Social Work, 25, 227-240.
Rastäm, M. (1992) Anorexia nervosa in 51 Swedish adolescents: premorbid problems and comorbidity. Journal of the American Academy of Child and Adolescent Psychiatry, 31, 819-829.[Medline]
Rastäm, M. & Gillberg, C. (1992) Background factors in anorexia nervosa: a controlled study of 51 teenage cases including a population sample. Journal of the American Academy of Child and Adolescent Psychiatry, 31, 819-829.[Medline]
Schlesselman, J. J. (1982) Case-Control Studies. Design, Conduct, Analysis. Oxford: Oxford University Press.
Shaw, B. & Garfinkel, P. (1990) Research problems in the eating disorders. International Journal of Eating Disorders, 9, 545-555.
Spielberger, C. D. (1983) Manual for the State-Trait Anxiety Inventory. Palo Alto, CA: Consulting Psychologists Press.
Wood, A., Waller, G., Miller, J., et al (1992) The development of Eating Attitude Test scores in adolescence. International Journal of Eating Disorders, II, 279-282.
Received for publication May 17, 1999. Revision received September 9, 1999. Accepted for publication September 10, 1999.