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Section of Child and Adolescent Psychiatry, University of Oxford, Warneford Hospital, Oxford, and Tavistock Centre, London, UK
Department of Psychiatry, University of Oxford, UK
Centre for Paediatric Epidemiology and Biostatistics, Institute of Child Health, University College London, UK
Correspondence: Professor Alan Stein, Section of Child and Adolescent Psychiatry, University of Oxford, Warneford Hospital, Oxford OX3 7JX, UK. Tel: +44 (0)1865 223911; fax +44(0)1865 226384; email: alan.stein{at}psych.ox.ac.uk
Declaration of interest None. Funding detailed in Acknowledgements.
* Freely available online through the British Journal of Psychiatry
open access option. 
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ABSTRACT |
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Aims To examine whether maternal eating disorders identified in the postnatal year are associated with the development of disturbed eating habits and attitudes in children at 10 years of age.
Method Follow-up comparative study of 56 families (33 mothers with eating disorders and 23 controls). Psychopathology of children, mothers and fathers was assessed by interview, and mother–child interaction observed.
Results The index group of children scored higher than controls on three of four domains of eating disorder psychopathology and on a global score. Children’s eating disturbance was associated with length of exposure to mothers’eating disorder and mother–child mealtime conflict at 5 years. There was some evidence of increased emotional problems in index children.
Conclusions The children of mothers with eating disorders manifested disturbed eating habits and attitudes compared with controls, and may be at heightened risk of developing frank eating disorder psychopathology.
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INTRODUCTION |
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TOPABSTRACTINTRODUCTIONMETHODRESULTSDISCUSSIONACKNOWLEDGMENTSREFERENCES |
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METHOD |
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TOPABSTRACTINTRODUCTIONMETHODRESULTSDISCUSSIONACKNOWLEDGMENTSREFERENCES |
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The demographic characteristics of the two groups are shown in Table 1. The social class distribution was similar in both index and control groups, with approximately equal proportions of middle class (non-manual) and working class (manual). The mean maternal age in both groups was almost identical. There was a slight preponderance of girls in the index group and boys in the control group. The infants were originally seen at home when they were between 12 and 14 months of age. When the children were 5 years old, they and their mothers were reassessed. All families had agreed to be seen at the 5-year visit, but one (in the index group) was excluded for the purposes of analysis because the mother had developed a life-threatening illness. At each time point, the mothers’ eating psychopathology was assessed in detail using a structured interview (Fairburn & Cooper, 1993).
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Procedure
The mothers and children were contacted again within 6 weeks of the
child’s tenth birthday, and families were visited at home. The study was
explained to the parents, who in turn discussed this with their children, and
signed consent was obtained. The researcher then explained the procedures to
the children in order to obtain their assent. It was made clear to the
children that, even if they agreed to take part, they could withdraw at any
time. Consent was obtained from the parents to contact the child’s
school for the completion of a teacher questionnaire. The study was approved
by the Oxfordshire Psychiatric Research Ethics Committee and the Royal Free
Hospital and Medical School Ethics Committee.
All but one of the families (in the control group) agreed to participate; this left 56 families. The index group comprised 33 firstborn children of mothers who had an eating disorder in the first year of the child’s life, and the control group comprised 23 firstborn children. Seven mothers were on their own at the 10-year follow-up. Four fathers declined to be interviewed, leaving a total of 45 fathers to be seen at 10 years. All assessments were carried out in the child’s home. The assessors were masked to the group status of the participants.
Child measures
Eating disorder psychopathology
The children’s eating disorder features were assessed using the Child
version of the Eating Disorder Examination (Child– EDE), an
investigator-based interview which measures the behavioural and ideational
features of eating disorders (Bryant-Waugh
et al, 1996). The Child–EDE generates a global
score and four sub-scale scores (restraint, eating concern, shape concern and
weight concern). In order to assess how these scores compared with a clinical
sample, data were obtained from a study of children referred to a tertiary
eating disorder clinic based in a children’s hospital
(Watkins, 2003). This clinical
sample comprised two main groups: 38 children with early-onset anorexia
nervosa (Cooper et al,
2002) and 42 with either early-onset food avoidance emotional
disorder or selective eating (Watkins,
2003). Early onset was defined as pre-menarchal for girls and
pre-pubertal for boys. Food avoidance emotional disorder is a term for a
childhood disorder of emotions in which food avoidance plays a prominent part,
but which does not meet diagnostic criteria for anorexia nervosa
(Higgs et al, 1989).
Selective eating refers to a childhood disorder characterised by the eating of
a very restricted range of foods
(Bryant-Waugh & Lask,
1995).
Scores on two items from the Child– EDE regarding overvalued ideas about shape and weight were also used to create a weight–shape overvalued ideas index, for examination alongside the Harter Self-Perception Profile, which measures self-esteem (see below). These items assess the degree of importance the child places upon shape and weight and their position in the child’s scheme of self-evaluation.
General psychopathology (emotional and behavioural adjustment)
The Strengths and Difficulties Questionnaire (SDS;
Goodman et al, 2000)
has 25 items concerning children’s emotional and behavioural adjustment.
It generates a global score and five sub-scales: emotional symptoms, conduct
problems, prosocial, hyperactivity and peer problems. Mothers, fathers and
teachers each completed the questionnaire.
The children underwent the Schedule for Affective Disorders and Schizophrenia for School-Aged Children (K–SADS) interview which provides a comprehensive mental state profile from which DSM–IV diagnoses and measures of severity can be derived (Kaufman et al, 1997). It is designed to measure current and recent psychological functioning.
The researchers adapted a diary sheet devised by the K–SADS trainer (Hartwin Sadowski, personal communication, 1997) to identify and map any events or experiences over the past 5 years which children recalled as both particularly important and as having a considerable impact on the way they felt. This mapping exercise preceded and eased the way into the K– SADS enquiry.
To assess self-esteem, the children completed a 36-item questionnaire, the Self-Perception Profile for Children (Harter, 1985), from which a global self-esteem score and five sub-scales scores (scholastic competence, athletic competence, physical appearance, social acceptance and behavioural conduct) can be derived.
The children’s weight and height were measured and their body mass index calculated (Cole et al, 1998).
Parental measures
Mothers’ eating habits, attitudes and eating psychopathology
These were measured using the Eating Disorder Examination (EDE;
Fairburn & Cooper, 1993).
This investigator-based interview assesses the full range of the
characteristic features 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. The EDE had been
previously administered to the mothers when the children were 1 and 5 years
old. At the 5- and 10-year assessments, the EDE was extended to obtain a
history of eating disorder features since the previous assessment. In this way
it was possible to calculate the total number of months that the mother had
experienced an eating disorder since the initial assessment at 1 year.
Mothers’and fathers’general psychopathology
Mothers and fathers were interviewed using the Major Depressive Disorder,
Generalised Anxiety Disorder and Obsessive Compulsive Disorder subsections of
the Schedule for Affective Disorders and Schizophrenia (SADS;
Endicott & Spitzer,
1978).
Marital adjustment
Both parents completed the Dyadic Adjustment Scale (DAS;
Spanier, 1976) to assess the
quality of the marital relationship. Two questions concerning perceived
marital criticism were added (Hooley &
Teasdale, 1989).
Mother–child conflict
Mother–child conflict/harmony ratings from mealtimes at 1 and 5 years
Videotaped observations of the mother and child during a mealtime when the
child was 1 and 5 years old had been rated as part of the earlier assessments.
At 1 year, conflict/harmony was rated every 2 min on a scale from 1 to 5
(Stein et al, 1994)
and again at 5 years, using a modified rating where 1=conflict and 5=harmony
(weighted kappa for the rating at 5 years=0.73). Conflict at 1 year was
defined as a battle for control between mother and infant with associated
infant distress, non-compliance and invariable disruption of feeding. Key
ingredients of this battle for control were a refusal to allow infants to feed
at their own pace and maternal concern about mess. At 5 years this definition
was modified to be a battle for control between mother and child, with the key
aspects being maternal insistence on the manner and amount of food eaten with
associated child distress, non-compliance and a subsequent disruption of the
mealtime.
Mother–child conflict/harmony at 10 years
Although each child was videotaped at 10 years during a mealtime, with a
view to rating participants’ interactions, the context of the meals was
so variable as to make consistent and reliable ratings impossible. We
therefore used other measures of parental critical behaviour, one from a
homework task and a second from a child mealtime questionnaire. In the
video-taped homework task (Murray et al, personal communication,
1997) the child completed two 20-min homework packs (maths and English), each
geared to get progressively harder and potentially provoke maternal guidance.
This task was carried out in the company of the mother who was available to
provide assistance. Maternal criticism/intrusiveness was rated from the
videotapes. Interrater reliability for event-sampled agreement on matched
events was 79%. For the purpose of analysis, this variable was dichotomised
for each mother–child pair (either occurring or not occurring). A brief
questionnaire was also designed to elicit from the child how often the family
ate together, and those aspects of mealtimes which the child liked or
disliked. Conflict was scored when children stated that conflictual dispute
was a dominant disliked feature of mealtimes.
Data analysis
First, univariate analyses were conducted using parametric and
non-parametric tests as appropriate, in order to compare the index and control
groups on the measures used. All tests were two-tailed. Second, multivariable
analyses were conducted to examine the independent influence of different
predictor variables on children’s eating disorder features. These
included the mother’s eating disorder psychopathology (current and when
the child was 1 and 5 years old), index/control status, total number of months
of maternal eating disorder since the child was 1 year of age, child gender,
marital adjustment and mother–child conflict at 1, 5 and 10 years.
Because the distribution of the children’s global EDE scores was skewed,
a regression model using Weibull-distributed errors with a logarithmic link
function was fitted. The response variable was 1 plus the global EDE score.
The models were fitted using S-PLUS2000 (MathSoft, Seattle, WA) on a Windows
platform. Because of the interest in gender differences, we also fitted
univariable Weibull models by gender for each of the EDE sub-scales.
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RESULTS |
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General psychopathology
Teacher ratings on the SDQ showed no significant differences between the
groups with respect to total score (index group mean 7.85, median 4,
s.d.=7.65; control group mean 5.39, median 5.0, s.d.=4.77, z=0.81).
However, the index group scored higher on the emotional symptoms subscale
(index group mean 1.76, median 2.0; control group mean 0.95, median 1,
z=1.95, P=0.051). There were no significant differences
between the groups on other sub-scales. Mothers’ and fathers’
ratings showed no significant differences between the groups on any of the
sub-scales or the total difficulties score.
No child fulfilled DSM–IV criteria for any diagnostic category in
K–SADS. There was a significant difference between the groups on one
item in the pre-interview life events mapping exercise, where the most
frequently mentioned response to upsetting events in the children’s
lives (such as separations/losses/major friendship upsets) was a persistent
sense of loneliness, described by 1 control (4%) and 12 (36%) index children
(
2=6.1, P <0.05; odds ratio 0.08, 95% CI
0.009–0.667).
There were no significant differences between the groups on the Harter global scores (control group mean 3.23, median 3.33, s.d.=0.61; index group mean 3.27, median 3.17, s.d.=0.36) or on any of the sub-scales.
There were no differences between the index and control groups in terms of body mass index (index mean 18.49, s.d.=3.27; control mean 18.07, s.d.=4.03, t=0.53, NS).
Parental measures
Mothers’ eating disorder psychopathology
Mothers in the index group scored significantly higher than controls on the
global EDE score as well as on each of the EDE sub-scales
(Table 4). In the index group
at the 10-year follow-up, three (9%) mothers fulfilled DSM–IV criteria
for bulimia nervosa and two (6%) fulfilled DSM– IV criteria for eating
disorder not otherwise specified. In addition, 14 (42%) mothers in the index
group and 3 (13%) mothers in the control group reported concerns about shape
and weight which were of clinical severity. Since the initial assessment when
the child was 1 year of age, the index group of mothers had experienced a full
eating disorder, either bulimia nervosa or unspecified disorder, for an
average of 15.96 months (s.d.=27.6). None of the control group mothers had
experienced an eating disorder.
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Mothers’and fathers’general psychopathology
Four index and two control mothers were found to have a current major
depressive disorder. Three index and one control mother fulfilled diagnostic
criteria for a current anxiety disorder. One index father and one control
father currently had a major depressive disorder disorder and one father from
each group currently had an anxiety disorder.
Marital adjustment
There were no significant differences between the groups on marital DAS
scores for either the fathers or the mothers.
Mother/child conflict
At 5 years, there was significantly more mealtime conflict between the
index mothers and children compared with controls on the conflict/harmony
scale, i.e. index mean 4.41 (s.d.=0.81); control mean 4.91 (s.d.=0.22),
t=3.33 (P <0.01).
At 10 years, there were no significant differences between the groups as to
whether the mother exhibited critical/conflictual behaviour during interaction
with her child during the homework task (2=1.4, NS); odds
ratio 0.34 (95% CI 0.08–1.43). There were also no significant
differences in the children’s reports concerning parental
criticism/disputes at meal-times (2=0.03, NS); odds ratio 0.74
(95 CI 0.21–2.59).
Influences on child eating psychopathology at 10 years
First, a regression model using Weibull-distributed errors was fitted with
child global EDE score as the dependant variable. The independent variables
included current maternal EDE scores, maternal EDE scores at 5 years, total
number of years since the child was 1 year old that the mother had experienced
an eating disorder, index/control status, mealtime conflict at 1 and 5 years
of age, conflict during the homework task at 10 years of age, child perception
of mealtime conflict at 10 years, marital adjustment at 10 years and
child’s gender. This was reduced using a backwards stepwise approach,
resulting in a model with two variables significantly related to the severity
of the child’s eating disorder features: the number of years since the
child was 1 year old that the mother had experienced an eating disorder
(z=4.10, P <0.0001; 95% CI 0.045– 0.127); and the
extent of mealtime conflict at 5 years of age (z=2.45, P
<0.01, 95% CI 0.053–0.489) (Table
5).
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DISCUSSION |
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TOPABSTRACTINTRODUCTIONMETHODRESULTSDISCUSSIONACKNOWLEDGMENTSREFERENCES |
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As rated by teachers, the index group showed some evidence of an increase in levels of emotional symptoms compared with controls, but this was not evident in parent ratings. There was little evidence of difference between groups on the K–SADS child interview, although it is of interest that a higher proportion of index children did describe a persistent sense of loneliness when faced with upsetting events. The two groups did not differ in their self-esteem. It therefore appears that, at 10 years of age, the difficulties manifested by these children were relatively specific to the eating weight/shape domain.
To our knowledge, this is the first study to report a longitudinal follow-up of children of mothers with eating disorders into middle childhood. There has been one longitudinal study which did not investigate an eating disorder cohort, but did examine the influence of maternal eating habits and attitudes, and found that particular maternal eating habits in the postnatal period were associated with child worries about being too fat and weight control behaviours in the daughters at 8 years of age (Jacobi et al, 2001). This provides broad support for the findings of the current study.
Possible mechanisms
The multivariable analyses indicate that two factors may have influenced
whether or not the children developed disturbed eating habits and attitudes:
first, the length of time a mother had experienced an eating disorder
(children whose mothers had experienced an eating disorder for longer
manifested more eating disorder psychopathology) and, second, the amount of
conflict between the mother and child during the child’s mealtime at 5
years. The stronger of these two factors, the length of exposure to maternal
eating psychopathology, raises the possibility that the mother’s eating
disorder influences the child directly. This is most likely to be brought
about by the child adopting eating behaviours and attitudes modelled by the
mother. Thus it appears that the longer children are exposed to dysfunctional
maternal eating habits and attitudes, the more likely they are to develop
dysfunctional eating habits and attitudes themselves. It is also possible that
some of these difficulties may have been owing to a genetic predisposition,
but the design of the study does not allow this issue to be addressed. The
finding that conflict between mothers and children during mealtimes is related
to the development of disturbed eating behaviours and attitudes indicates that
there may be a specific way in which mothers influence their children’s
eating behaviours and attitudes, in that mealtimes become a major source of
contention which communicates to the child an overvalued importance of the
manner in which the child eats and the amount eaten.
Strengths and limitations
The strengths of the study include the fact that it was a prospective
longitudinal study with an almost complete follow-up of the sample over a
9-year period. At each time point careful assessment was made of both maternal
and child psychopathology using standardised interview methods, and
mother–child interaction was examined by direct observation. There was a
number of limitations. The size of the sample was relatively small, and
therefore further studies are required to confirm these findings. It was not
possible to obtain robust direct observational mealtime data at 10 years, and
this probably reflects the nature of family life with children of that age,
when children are less likely to sit down alone with their mothers on a
regular basis to eat a meal. None the less, information about mealtime
conflict was obtained from child reports. Finally, no assessment of the
fathers’ eating disorder psychopathology at 10 years was made, although
their general psychopathology was assessed.
Inferences
At 10 years of age, the children of mothers with eating disorders had a
raised level of disturbances in eating habits and attitudes compared with
controls, but there was little evidence of increased general psychopathology.
This suggests that maternal eating disorders might have a specific adverse
effect on the children’s eating habits and attitudes. Although there was
no evidence that children had frank eating disorders at 10 years of age, it is
of concern that, even at such a young age, they were more likely to be dieting
and holding overvalued ideas about body shape and weight in their scheme of
self-evaluation. Follow-up into adolescence of these kinds of samples is
required to determine the longer-term outcome for such children, who may be at
heightened risk of developing more severe forms of eating disorder
psychopathology, including frank eating disorders. Further research is
required to establish whether identifying and treating mothers with eating
disorders and conflictual interaction between mothers and children at
mealtimes reduces the risk of children developing disturbances in their own
eating habits and attitudes.
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ACKNOWLEDGMENTS |
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TOPABSTRACTINTRODUCTIONMETHODRESULTSDISCUSSIONACKNOWLEDGMENTSREFERENCES |
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REFERENCES |
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TOPABSTRACTINTRODUCTIONMETHODRESULTSDISCUSSIONACKNOWLEDGMENTSREFERENCES |
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American Psychiatric Association (1980) Diagnostic and Statistical Manual of Mental Disorders (3rd edn, revised) (DSM–III–R). Washington, DC: APA.
Bryant-Waugh, R. & Lask, B. (1995) Eating disorders in children. Journal of Child Psychology and Psychiatry, and Allied Disciplines, 36, 191 –202.[Medline]
Bryant-Waugh, R., Cooper, P. J., Taylor, C. L., et al (1996) The use of the eating disorder examination with children: a pilot study. International Journal of Eating Disorders, 19, 391 –397.[CrossRef][Medline]
Cole, T. J., Freeman, J.V. & Preece, M. A. (1998) British 1990 growth reference centiles for weight, height, body mass index and head circumference fitted by maximum penalized likelihood. Statistics In Medicine, 17, 407 –429.[CrossRef][Medline]
Cooper, P. J., Watkins, B., Bryant-Waugh, R., et al (2002) The nosological status of early onset anorexia nervosa. Psychological Medicine, 32, 873 –880.[CrossRef][Medline]
Endicott, J. & Spitzer, R. L. (1978) A diagnostic interview: the schedule for affective disorders and schizophrenia. Archives of General Psychiatry, 35, 837 –844.[Abstract]
Fairburn, C. G. & Cooper, Z. (1993) The Eating Disorder Examination (12th edn). In Binge Eating: Nature, Assessment, and Treatment (eds C.G. Fairburn & G. T. Wilson), pp. 317–360. New York, NY: Guilford Press.
Goodman, R., Ford, T., Simmons, H., et al
(2000) Using the Strengths and Difficulties Questionnaire
(SDQ) to screen for child psychiatric disorders in a community sample.
British Journal of Psychiatry,
177, 534
–539.
Harter, S. (1985) Manual for the Self-Perception Profile for Children. Denver, CO: University of Denver.
Higgs, J. F., Goodyer, I. M. & Birch, J. (1989) Anorexia nervosa and food avoidance emotional disorder. Archives of Disease in Childhood, 64, 346 –351.[Abstract]
Hill, A. J., Oliver, S. & Rogers, P. J. (1992) Eating in the adult world: the rise of dieting in childhood and adolescence. British Journal of Clinical Psychology, 31, 95 –105.[Medline]
Hill, A. J., Draper, E. & Stack, J. (1994) A weight on children’s minds: body shape dissatisfactions at 9 years old. International Journal of Obesity and Related Metabolic Disorders, 18, 383 –389.
Hooley, J.M. & Teasdale, J.D. (1989) Predictors of relapse in unipolar depressives: expressed emotion, marital distress, and perceived criticism. Journal of Abnormal Psychology, 98, 229 –235.[CrossRef][Medline]
Jacobi, C., Agras, W. S. & Hammer, L. (2001) Predicting children’s reported eating disturbances at 8 years of age. Journal of the American Academy of Child and Adolescent Psychiatry, 40, 364 –372.[CrossRef][Medline]
Kaufman, J., Birmaher, B., Brent, D., et al (1997) Schedule for Affective Disorders and Schizophrenia for School-Age Children–Present and Lifetime Version (K–SADS–PL): initial reliability and validity data. Journal of the American Academy of Child and Adolescent Psychiatry, 36, 980 –988.[CrossRef][Medline]
Patel, P., Wheatcroft, R., Park, R. J., et al (2002) The children of mothers with eating disorders. Clinical Child and Family Psychology Review, 5, 1 –19.[Medline]
Rutter, M. (1989) Psychiatric disorder in parents as a risk factor for children. In Prevention of Mental Disorder, Alcohol and Other Drug Use in Children and Adolescents (eds D. Shaffer, I. Phillips & N. B. Enger), pp. 157 –189. Rockville, MD: Office for Substance Abuse US DHHS.
Spanier, G. B. (1976) Measuring dyadic adjustment: new scales for assessing the quality of marriage and similar dyads. Journal of Marriage and the Family, 38, 15 –28.[CrossRef]
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, and Allied Disciplines, 35, 733 –748.[Medline]
Watkins, B. (2003) Differentiating Early Onset Eating Disorders. PhD Thesis. Reading: University of Reading.
Whelan, E. & Cooper, P. J. (2000) The association between childhood feeding problems and maternal eating disorder: a community study. Psychological Medicine, 30, 69 –77.[CrossRef][Medline]
Received for publication June 15, 2005. Revision received January 11, 2006. Accepted for publication March 3, 2006.
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