Fundamental interactions: mothers and children, feeding and eating

1
Fundamental interactions mothers and children,
feeding and eating

• Rachel Bryant-Waugh
• Great Ormond Street Hospital, London, UK
• 6th Annual Conference of the Australian and New
  Zealand Academy for Eating Disorders
• Fremantle WA, August 2008

2
Presentation outline

• Background and context for this talk
• Explore three main areas
• Mothers with eating disorders
• Children with feeding problems
• Linking feeding and eating problems
• Try to pull together these different strands
• to think about where this leaves us as
  clinicians

3
Background

• Long standing clinical and research interest in
  eating disorders through experience in
• Clinic for young children
• with feeding disorders and
• other feeding problems
• Residential and out-patient
• services for older children and
• adolescents with eating
• disorders and other clinical
• eating disturbances

4
Background

• At community based
• adult ED service developed particular clinical
  and research interest in mothers
• Belief in importance of understanding the
  emergence and maintenance of presenting problems
  in a developmental and systemic framework across
  the age range

5
Some observations

• Sizeable number of adult ED patients are mothers,
  and parenting and feeding issues often come up in
  therapy
• Many mothers of children
• with feeding problems experience
• significant anxiety effect on
• feeding/how best to address?
• Curious lack of joined up thinking and practice
  in relation to problems with feeding and eating
  in children and adolescents

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All of which led to.

• An increasing interest in exploring links between
  
• mothers-children-feeding-eating
• Thinking this is an area with under developed and
  
• under researched preventative potential
• An acknowledgement that there is very limited
• evidence about specific interventions and their
  effect
• Corresponding recognition that there is potential
  for developing targeted interventions

7
Presentation outline

• Background and context for this talk
• Explore three main areas
• Mothers with eating disorders
• Children with feeding problems
• Linking feeding and eating problems
• Try to pull together these different strands
• to think about where this leaves us as
  clinicians

8
Brief look at some of the literature

• What do we know from research about
• Mothers with eating disorders and their children?
• Children with feeding disorders and their
  mothers?
• Feeding disorders predisposing to eating
  disorders?

9
Mothers with EDs

• 5 year prospective study found that compared to
  infants of non ED mothers, female infants of ED
  mothers
• Suckled faster at 2 and 4 weeks
• Weaned from bottle feeding on average 9 months
  later and with more difficulty
• Experienced higher rates of vomiting
• Children of mothers with ED showed more negative
  affect, crying and irritability, at 5 yrs
  Agras et al, 1999

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Mothers with EDs

• Same study also found that compared to controls,
  mothers with EDs
• Had a less organised schedule of feeding
• Were more likely to used food for non-nutritional
  purposes - to reward or calm the child
• Had significantly greater concerns about their
  daughters weight (from 2yrs onwards)
• Agras et al, 1999

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Mothers with EDs

• Observational study of mothers and 1 year olds
  found
• ED mothers more likely to express negative
  comments towards infants during mealtimes
• More likely to be intrusive during mealtimes
  cutting across and/or disrupting the infant
• More likely to miss infants cues
• More conflict at mealtimes
• Children of mothers with ED weighed less
• Stein et al, 1994

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Mothers with EDs

• In relation to general parenting function,
  compared to controls, mothers with EDs found to
• Be more verbally controlling and intrusive, and
  less facilitating during play (Stein
  et al, 1994)
• Use more strong verbal control (e.g. commands,
  prohibits, forbids, cautions, corrects) but show
  no difference in use of gentle verbal control
  and physical contact
  (Stein et al, 2001)

13
Brief look at some of the literature

• What do we know from research about
• Mothers with eating disorders and their children?
• Children with feeding disorders and their
  mothers?
• Feeding disorders predisposing to eating
  disorders?

14
Children with FDs

• Quality of mother-child interactions compromised
  when child has feeding difficulties
• e.g. Chatoor et al 1998 Cooper et al 2004
  Lindberg et al 1996
• Mothers of children with feeding problems
  higher levels of depression, anxiety, eating
  disorders, mood and personality disorders
• Ammaniti et al 2004 Couthard Harris 2003
  Duniz et al 1996 Timimi et al 1997
• Higher rates of obsessional cleanliness apparent
  in mothers of children with feeding problems
• Douglas Harris 2001

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Children with FDs

• Greater difficulties with communication and lower
  levels of problem solving Unlu et al 2006
• Higher levels of emotional distress Budd et al
  1990
• Higher levels of parenting stress Kerwin Reider
  1994 singer et al 1990 Spender et al 1996

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Children with FDs

• Low maternal self-esteem and social isolation
  beliefs predict maternal report of child feeding
  problems Farrow and Blissett 2006
• Mothers who measure maternal competence by how
  and how much child eats greater frequency of
  dysfunctional interaction during feeding than
  controls Chatoor 2000 Lindberg et al 1996

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Children with FDs

• Mothers of children with FDs (at 4 years) showed
  higher rates of past/current EDs compared to
  mothers of children with non-feeding related
  problems (Whelan et al, 2000)
• Mealtime disorganisation and high levels of
  maternal control and disharmony found to mediate
  the relationship between maternal ED and child
  feeding difficulties (Cooper et al, 2004)

18
Brief look at some of the literature

• What do we know from research about
• Mothers with eating disorders and their children?
• Children with feeding disorders and their
  mothers?
• Feeding disorders predisposing to eating
  disorders?

19
Feeding disorders Eating disorders

• In a retrospective study childhood feeding
  difficulties (feeding problems as a baby,
  mealtime difficulties, food refusal and food
  fads) associated with pre-pubertal AN in
  retrospective controlled study comparing pre and
  post pubertal AN Jacobs Isaacs 1986

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Feeding disorders Eating disorders

• In a longitudinal study digestive problems and
• picky eating prospectively related to subsequent
  anorexic symptoms, and anorexic symptoms related
  to full diagnoses of AN
• Pica, early digestive problems, and weight
  reduction efforts related to later bulimic
  symptoms with risk of BN 7 times higher in those
  with history of pica in early childhood
  Marchi and Cohen 1990

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Feeding disorders Eating disorders

• In a longitudinal study - early eating conflicts,
  struggles with meals, unpleasant meals predicted
  later diagnosis of AN
• Eating too little in early childhood predictive
  of future BN Kotler et al 2001

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Feeding disorders Eating disorders

• In overview paper of risk factors for ED Picky
  eating, anorexic symptoms in childhood, digestive
  and other early eating-related problems as well
  as mealtime/eating conflicts, struggles,
  unpleasantness variable risk factors for AN or
  anorexic symptoms replication needed
• Results of longitudinal studies inconclusive with
  regard to risk for BN further research needed
• Jacobi 2004

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Feeding disorders Eating disorders

• Our own small follow-up of children with FD
• 76 completed EAT-26 questionnaires
• 4 (5.26) scored above the cut-off of 20 for the
  questionnaire
• 82 completed HADS questionnaires
• 9 (10.98) scored above the cut-off score of 11
  for the anxiety subscale.
• 1 (1.21) scored above the cut-off score of 11
  for the depression subscale.
• (unpublished GOSH data)

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Equally important..

• What do we know clinically about
• Mothers with eating disorders and their children?
• Children with feeding disorders and their
  mothers?
• Feeding disorders predisposing to eating
  disorders?

25
Clinical observations

• Mothers with eating disorders and their children

• Worry about passing on their difficulties
• Often feel unsure how about how best to feed
  their children
• Find it very difficult to ask for help and
  support in this area

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Clinical observations

• Children may not be exposed to changing level of
  expectation and challenge
• Fathers may be excluded or their input may be
  experienced as undermining
• Mothers experience isolation and lack of
  understanding as well as anxiety and frustration

• Children with feeding disorders and their mothers

27
Clinical observations

• Variable feeding histories in children and
  adolescents with EDs
• Some young people described as having been faddy
  eaters without having had a formal feeding
  problem
• Some overlap in relation to anxiety and control
  issues

• Feeding disorders predisposing to eating
  disorders

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Conclusions 1

• Feeding occurs in a relationship, and is affected
  by both maternal and child characteristics
• Pathway from feeding disorder to eating disorder
  likely to involve other mediator or moderator
  variables
• Anxiety emerges as a potential key variable

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Conclusions 2

• Mothers with EDs may find general aspects of the
  parenting role as well as feeding more
  challenging
• Eating psychopathology in mothers may increase
  the risk of their children developing feeding
  difficulties
• This may increase the risk of the child
  developing an ED in later life

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Presentation outline

• Background and context for this talk
• Explore three main areas
• Mothers with eating disorders
• Children with feeding problems
• Linking feeding and eating problems
• Try to pull together these different strands
• to think about where this leaves us as
  clinicians

31
Mothers and children, feeding and eating the
story so far.

• Feeding
• Mothers Children
• Eating Eating
• Modeling effects/messages/attitudes

32
Mothers and children, feeding and eating the
story so far.

• Feeding
• Mothers Children
• Eating Eating
• Modeling effects/messages/attitudes

33
Mothers and children, feeding and eating the
story so far.

• Feeding
• Mothers Children
• Eating Eating
• Modeling effects/messages/attitudes

34
Mothers and children, feeding and eating the
story so far.

• Feeding
• Mothers Children
• Eating Eating
• Modeling effects/messages/attitudes

35
Mothers and children, feeding and eating the
story so far.

• Feeding
• Mothers Children
• Eating Eating
• Modeling effects/messages/attitudes

36
Central thesis for this talk

• Clinicians working in the field of eating
  disorders pay insufficient attention to the
  fundamental importance of feeding in a
  relationship context

37
Possible ways forward

• Growing consensus that mothers with eating
  disorders may benefit from specific support
  around feeding and general parenting
• Development of skills and support group for
  mothers of under 5s to enhance mother-child
  interaction

38
Themes for group sessions

• Interactions around food and mealtimes
• Food preparation and provision
• Mothers intake
• Self care
• Self identity and parental expectations
• Need for control
• Impact of the ED on the general parent-child
  relationship

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Feedback from mothers

• Helpful to hear how others manage feeding, and
  young children generally, and to try new ideas
  difficulties in coping with cooking and preparing
  food for child diminished
• Provided opportunity to express concerns in a
  supportive, non-threatening context as all had
  EDs
• Sense of isolation as mother with
• an ED diminished
• Greater sense of other people finding
• children hard work

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From facilitators perspective

• Felt worthwhile - feedback positive
• and mothers actively involved in trying
• to do things differently
• Very impressed by warmth and
• generosity of the women towards each other
• Scores improved on pre- and post measures of
  depression and parenting concerns at end of group
  and maintained at follow-up change less on self
  esteem

41
Building on this work

• Development of skills and support group for
  mothers of children with feeding problems

• Parenting a child who is difficult to feed
• Feelings of social isolation and incompetence
• Affects mothers perception of childs
  difficulties
• Further disruption of feeding interaction

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Themes for group sessions

• Stress of parenting a child with feeding disorder
• Food preparation and provision
• Mealtime interactions
• Self identity, support and parenting
• competence
• Impact on the general parent-child relationship
• Concerns for the future

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Measures

• Parental evaluation of the feeding problem
• Parenting concerns and competence
• Parenting stress
• Anxiety and depression
• Social support
• Significant events

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Overall aims

• to increase social and emotional support for
• mothers of children with feeding problems
• to provide mothers with skills and strategies
  aimed at increasing positive feeding interactions
• to support mothers in providing positive
  encouragement of normal developmental
• changes
• to provide education and advice about
• normal child development and parenting
• a child with chronic feeding difficulties

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Outcomes?

• such a group unlikely to have an early direct
  effect on child feeding problems
• may change the mother-child interactions through
  influencing parental attitudes and behaviours in
  relation to the feeding problem.
• focus on providing emotional and
• educational support and addressing
• low mood and parenting stress not
• on feeding problem per se

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What about feeding eating?

• If high risk, need to understand better what
  types of feeding problem or related factors are
  accounting for the risk
• Might allow for targeted interventions
• Might suggest increased need
• for monitoring for some children

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Back to our follow-up study

• Contrary to expectation children with early
  selective eating no more likely than children
  with early feeding difficulties due to organic
  disease to develop significant ED psychopathology
  in adolescence.
• Trend towards SE children
• having higher risk, especially
• for bulimic features.
• Some evidence that anxiety
• plays a mediator role

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• To conclude.

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Feeding is a fundamental interaction

• Essential early behaviour occurring in the
  context of relationship between caregiver and
  infant
• Nature of feeding relationship contributes to
  development of healthy attachment, in turn
  related to lifelong patterns of relating to
  others
• Parental negotiation of the childs
• transition from feeding to eating is
• inextricably linked to childs
• developing autonomy, sense of
• self control and mastery over self
• and others

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And we need to pay more attention to it!!

• Clinicians working in the field of eating
  disorders pay insufficient attention to the
  fundamental importance of feeding in a
  relationship context

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Thank you for listening!