fundamental interactions: mothers and children, feeding and eating

1. 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

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

6. 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

10. 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 daughter�s weight (from 2yrs onwards) Agras et al, 1999

11. 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 infant�s cues More conflict at mealtimes Children of mothers with ED weighed less Stein et al, 1994

12. 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

15. 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

16. 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

17. 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

20. 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

21. 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

22. 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

23. 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)

24. 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

26. 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 Feeding disorders predisposing to eating disorders 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

28. 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

29. 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

30. 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 5�s 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

39. 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

40. 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 mother�s perception of child�s difficulties Further disruption of feeding interaction

42. 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

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

44. 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

45. 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

46. 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

47. 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

48. To conclude�.

49. 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 child�s transition from feeding to eating is inextricably linked to child�s developing autonomy, sense of self control and mastery over self and others

50. 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

51. Thank you for listening!