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Keywords:

  • child feeding;
  • anxiety;
  • control;
  • restriction;
  • psychopathology

Abstract

  1. Top of page
  2. Abstract
  3. Introduction
  4. Research Methods and Procedures
  5. Results
  6. Discussion
  7. Acknowledgement
  8. References

Objective: To investigate the relationship between maternal psychopathological symptomatology during pregnancy and at 6 and 12 months postnatally and maternal use of controlling and restrictive feeding practices at 1 year.

Research Methods and Procedures: Eighty-seven women completed a measure of psychological distress during pregnancy and at 6 and 12 months postpartum, and at 12 months postnatally these women reported their usage of controlling and restrictive feeding practices and were observed feeding their infants.

Results: General psychological distress, particularly anxious psychopathology, during pregnancy and at 6 and 12 months postnatally was significantly associated with maternal use of restrictive feeding practices at 1 year, even when controlling for length of breast-feeding and the infants’ weights at 1 year. Contrary to expectations, depression and eating psychopathology as measured by the SCOFF eating disorder measure during pregnancy or at 6 or 12 months postnatally were not associated with the use of controlling or restrictive feeding practices at 1 year.

Discussion: These findings indicate that anxious maternal psychopathology may partially explain the development of maternal use of restriction when feeding.


Introduction

  1. Top of page
  2. Abstract
  3. Introduction
  4. Research Methods and Procedures
  5. Results
  6. Discussion
  7. Acknowledgement
  8. References

In our obesigenic society, where the pressure to maintain a thin body ideal is in constant conflict with the increasing prevalence of highly palatable, fat-laden foods, many parents use controlling feeding practices to try to protect their children from the risk of becoming obese (1). These controlling and forceful feeding practices are associated with the prevalence of both feeding problems and overweight in childhood (2,3). Despite the often desired effect of improving child food intake of healthy foods, the expression of control over feeding and food is believed to have the converse discounting effect of teaching children to dislike forced food and to prefer controlled or restricted foods (4). Controlling feeding strategies such as coercing the child to eat, distracting the child to eat, or force feeding are also commonly reported in dyads with feeding problems such as food fussiness (5,6,7,8,9). Moreover, in the general population, controlling feeding techniques such as pressure to eat or restriction are associated with decreased child self-regulation of intake, with decreased fruit and vegetable consumption, child dietary restraint, disinhibition, and obesity (2,3,4,10,11,12). In addition, experimental free-access procedures provide longitudinal evidence that maternal restriction of food at 5 years of child age predicts their daughters’ eating in the absence of hunger at 7 and 9 years of age (13), and controlling or forceful feeding practices in childhood have even been shown to shape fussy food preferences in adulthood (14). Given the important detrimental effects of controlling feeding behaviors, it is imperative to understand the factors that motivate caregivers to use these strategies when feeding.

Aside from the fact that caregivers are more likely to control child food intake when children are perceived to be over- or underweight (15), various other factors may also motivate the use of controlling feeding practices. A wealth of literature has implicated maternal mental health problems (particularly eating disorders, depression, and anxiety) in the onset and continuation of child feeding problems (16,17,18), a relationship presumably mediated by the use of detrimental feeding practices. Indeed, recent research has found that maternal weight, restrained eating, body dissatisfaction, and history of eating disorder psychopathology predicts maternal use of restriction and pressure to eat when feeding their children (1,19). Furthermore, maternal control mediates the effect of maternal eating disorder psychopathology on child feeding problems (20). Similarly, other factors have been identified that may predispose caregivers to use controlling or restrictive feeding practices: younger, less educated, multigravida women are more likely to restrict food intake at 1 year (21); women who breast-feed are less likely to restrict or control their children's food intake (12,21); and ethnic minority status has also been related to the use of these feeding practices (19). Despite the identified relationship between maternal eating disorder and the use of controlling feeding practices, there is a dearth of research exploring the relationship between other aspects of parental psychopathology associated with feeding problems (e.g., depression, anxiety) and the use of controlling feeding practices. In a recent study of twins, Wardle et al. (22) has suggested that maternal feeding styles are not responsive to genetic child factors, suggesting a greater need to investigate the parental factors that predispose the use of these feeding styles.

In our search to identify the parental factors predicting the use of detrimental feeding practices, there is a paucity of longitudinal data, leaving at question the direction of the claimed relationship between maternal factors and the use of controlling feeding strategies that may represent reactive or responsive strategies to attempt to control child weight. An appreciation of the relationship between maternal psychopathology and the use of controlling feeding practices would, thus, represent a significant step toward informing present understanding of how maternal mental health may be related to child feeding. The present research uses a non-clinical, longitudinal study initiated in pregnancy to explore the relationship between maternal psychopathology and the later use of controlling feeding practices, before factors such as breast-feeding, child weight, and appetite can influence the direction of the relationships. It was hypothesized that, independently of infant weight and length of breast-feeding, maternal anxiety, depression, and eating psychopathology during pregnancy and at 6 and 12 months postnatally would be significantly associated with validated maternal reports of controlling and restrictive feeding practices at 1 year.

Research Methods and Procedures

  1. Top of page
  2. Abstract
  3. Introduction
  4. Research Methods and Procedures
  5. Results
  6. Discussion
  7. Acknowledgement
  8. References

Participants

After receiving permission from the South Birmingham NHS Ethics Committee, 87 women were recruited for this study during pregnancy from antenatal clinics throughout the West-Midlands, United Kingdom. All women gave informed consent to participate in this research and complete follow-up questionnaires when their children were 6 months and 1 year of age. The mean age of these women on recruitment to the study was 31.67 years (SD = 5.46). Sixty-two women breast-fed their babies, and 25 exclusively bottle-fed. Of the 62 women who breast-fed, the mean length of breast-feeding was 30 weeks (range, 1 month to 55 weeks).

Measures

Psychopathology

To assess psychopathological distress, the Brief Symptoms Inventory (BSI)1 was used (23). The BSI is a widely used comprehensive tool to assess psychopathological distress, including: somatization, obsessive-compulsiveness, interpersonal sensitivity, depression, anxiety, hostility, phobic anxiety, paranoid ideation, and psychoticism. The BSI also assesses general psychopathological functioning as indicated by a Global Severity Index. The BSI correlates well with its counterpart Symptom Checklist (SCL-90-R) dimensions, with individual scale correlations ranging from 0.92 to 0.99 (23,24), and also correlates with the Brief Psychiatric Rating Scale and the Minnesota Multiphasic Personality Inventory, two of the finest psychiatric rating scales (24,25). Factor analysis supports the construct validity of the BSI, and it has also been shown to have excellent internal consistency, test-retest reliability, and convergent and discriminant validity with measures of psychopathology (23,24). Despite the wide range of symptomatology assessed by the BSI, the instrument does not assess eating disorder symptomatology; consequently, the SCOFF eating disorder measure was also administered for this purpose (26). SCOFF is an acronym for a concise, valid, and reliable set of five questions regarding eating and dieting, where answering yes to two or more questions is seen as indicative, but not diagnostic, of an eating disorder. The SCOFF has good discriminant validity and reliability with patients with eating disorders (26,27), providing 100% sensitivity to detect anorexia and bulimia nervosa and 84.6% sensitivity when also assessing eating disorders not otherwise specified (25,28). Both the BSI and SCOFF were administered to participants during pregnancy and at 6 and 12 months postpartum.

Feeding Control

The Child Feeding Questionnaire (CFQ) (29) was administered to assess maternal control over child feeding. Two subscales of the CFQ were used specifically to assess parental control over child feeding: parental pressure to eat and restriction of food. Higher scores on these subscales indicate greater control over child feeding. The CFQ is widely used to assess parental control over child feeding (2,11,12,15), and these subscales have good internal consistency (29). These subscales of the CFQ were administered at 1 year only because the CFQ is inappropriate for infants as young as 6 months of age.

Mealtime Observations

Seventy-four of these mother-child dyads were observed during feeding of the children at 1 year. All meals were observed in the home, as normal, and behavior was recorded using a video camera. The Feeding Interaction Scale (FIS) (30) was used to code maternal and child behavior during the mealtime. The FIS assesses various aspects of maternal and child interactional behavior, but only specific observational measures that could be deemed representative of pressure to eat or restriction are reported here: maternal use of verbal and physical control when feeding, as well as the number of offers of food given and the total amount of food consumed by the child. Counts of the incidence of force feeding were also observed as an indicator of pressure to eat. It is difficult to specifically observe general self-report feeding measures, and it is acknowledged that these observation measures do not identically reflect the pressure to eat or restriction subscales of the CFQ; however, these observation codes were deemed the most appropriate measures from the FIS to validate maternal report. The FIS has clinical validity and has been used to assess maternal-child feeding interactions and to diagnose feeding problems (7,9,31). Of the 1-year videos, 19% were recoded by a trained observer who was familiar with the coding procedure. Intraclass correlations were calculated between the two observers to assess interrater reliability. The mean intraclass correlation coefficient was 0.749, and the mean level of significance was p < 0.05.

Infant Weight and Gender

Infant gender was noted, all infants were weighed naked at 1 year with electronic scales, and infant weight was then converted into standardized z scores accounting for gender and age in weeks using the Child Growth Foundation reference curves disc (32).

Data Analysis

Descriptive statistics were performed. Due to previously identified gender differences in the use and consequences of controlling feeding practices (33,34), independent sample t tests were performed to establish whether mothers of male and female children differed in their use of control when feeding or their reports of psychopathology at 6 or 12 months. No significant differences were found; as such, the two groups were homogenized for further analysis.

To date, there is a lack of research validating parental reports of the use of controlling feeding practices with independent observations. To establish the validity of maternal reports of controlling feeding practices, Pearson's one-tailed correlations were used to compare maternal reports with independent observations of behaviors that are indicative of pressure to eat (use of verbal and physical control at mealtimes, incidence of force feeding) and restriction (number of times food was offered and eaten).

To control for the contribution of infant weight and length of breast-feeding to the use of controlling feeding practices, partial correlations were used controlling for these variables. Partial correlations were used to examine the relationships between maternal psychopathology during pregnancy and at 6 and 12 months postpartum and the use of controlling feeding practices at 1 year. One-tailed tests were used because the hypotheses were directional, i.e., that increased maternal psychopathology would correlate with more controlling feeding practices. The two aspects of maternal control were evaluated separately to examine whether different aspects of psychopathology were differentially associated with pressure to eat or restriction. Finally, independent sample t tests were performed to establish whether women identified by the SCOFF as potentially having/not having eating disorders during pregnancy or at 6 or 12 months postpartum had infants with different weights at 1 year or reported different use of pressure to eat or restriction at 1 year. For these analyses, Bonferroni corrections dictated the use of an α of 0.001 to reduce the risk of Type 1 errors.

Results

  1. Top of page
  2. Abstract
  3. Introduction
  4. Research Methods and Procedures
  5. Results
  6. Discussion
  7. Acknowledgement
  8. References

Descriptive Statistics

Table 1 presents the mean and SD scores for the BSI and CFQ. Fourteen and nine-tenths percent of the women were identified by the SCOFF as potentially having an eating disorder during pregnancy, 18.4% at 6 months, and 11.5% at 1 year postpartum. The mean scores for the CFQ are similar to those reported previously, although the mean restriction scores are slightly lower than those reported by North-American parents of school-aged children (1,29), perhaps reflecting sociocultural differences between the U.S. and the United Kingdom or the younger age group used here. The mean scores for the BSI are broadly comparable, but slightly lower, than those reported elsewhere (23).

Table 1. . Descriptive statistics for the BSI during pregnancy and at 6 and 12 months postnatally and for the CFQ at 1 year
 Pregnancy 6 months 1 year
  1. Scales not measured at this time.

 MeanSDMeanSDMeanSD
BSI      
 Somatization55.138.7948.268.1346.497.57
 Obsessive-compulsiveness53.799.4254.649.8752.259.28
 Interpersonal sensitivity49.568.5248.219.0347.439.22
 Depression48.487.5749.538.4647.958.32
 Anxiety49.619.4546.239.3044.598.79
 Hostility54.329.6351.619.7251.558.41
 Phobic anxiety49.316.8047.536.1247.075.61
 Paranoid ideation49.608.1248.258.0048.998.09
 Psychoticism50.787.6950.538.1549.826.98
 Global Severity Index52.018.8048.7410.3546.999.52
CFQ      
 Pressure to eat----2.240.93
 Restriction----2.500.76

Validation of Reports of Controlling Feeding Practices

One-tailed Pearson's correlations were performed correlating maternal report with independent mealtime observations to validate maternal reports of controlling feeding practices. Maternal report of pressure to eat and restriction correlated significantly at p < 0.01 with appropriate observations of maternal feeding behaviors. Specifically, as indicated in Table 2, maternal report of pressure to eat correlated significantly with observations of greater maternal verbal control and physical control, force feeding, and consumption of less food. In addition, maternal report of restriction correlated significantly with independent observations of offering less food to the child and of the child consuming less food. (In Table 2, higher scores on verbal and physical control indicate that less control was exhibited by the mother.)

Table 2. . Pearson's correlations between observations and maternal report of feeding practices
 Maternal report
  • *

    p < 0.01.

ObservationPressure to eatRestriction
Maternal verbal control−0.432*0.087
Maternal physical control−0.345*0.100
Number of force-feeding attempts0.351*−0.107
Number of offers of food made−0.016−0.365*
Amount of food consumed−0.278*−0.346*

Relationships between Maternal Psychopathology and Maternal Control over Feeding

One-tailed partial correlations, controlling for length of breast-feeding and infant weight at 1 year, were performed to evaluate whether maternal psychopathology during pregnancy and at 6 or 12 months postnatally correlated with maternal report of pressure or eat or restriction at 1 year. Table 3 displays the correlations between controlling feeding practices and maternal psychopathology, controlling for infant weight, and length of breast-feeding. There were no significant correlations between maternal depression, interpersonal sensitivity, hostility, phobic anxiety, or psychoticism during pregnancy or at 6 or 12 months postpartum and maternal restriction or pressure to eat at 1 year. As Table 3 indicates, maternal pressure to eat at 1 year did not correlate significantly with any aspects of psychopathology during pregnancy or at 6 or 12 months postnatally. Conversely, maternal use of restriction at 1 year correlated significantly with prenatal maternal anxiety and paranoid ideation, with somatization and anxiety at 6 months, and with obsessive-compulsiveness at 1 year. Maternal restriction also correlated significantly with maternal Global Severity Index scores (indicative of general psychopathological dysfunctioning) during pregnancy and at 6 months postnatally.

Table 3. . Partial correlations, controlling for length of breast-feeding and infant weight at 1 year, between controlling feeding strategies and maternal psychopathology during pregnancy and at 6 and 12 months postpartum
 Controlling feeding practices at 1 year
  • *

    p ≤ 0.001

 Pressure to eat Restriction
 Pregnancy6 months1 yearPregnancy6 months1 year
Somatization0.1850.0640.0900.2660.348*0.223
Obsessive-compulsiveness0.1170.0320.1290.2140.2620.385*
Interpersonal sensitivity0.0790.0250.0810.1900.1600.216
Depression0.2440.1730.1930.2210.2650.274
Anxiety0.1920.1440.1110.334*0.361*0.203
Hostility0.152−0.1180.0340.1230.0370.192
Phobic anxiety0.1950.2790.1200.1470.3100.238
Paranoid ideation0.2020.1350.2250.392*0.2450.125
Psychoticism0.2450.0850.1430.3070.1430.125
GSI0.1900.0900.1250.374*0.328*0.305

To ascertain that the relationship between prenatal maternal anxiety and maternal restriction at 1 year postpartum was not a function of postnatal maternal anxiety, a regression was performed using prenatal maternal anxiety to predict restriction at 1 year, controlling for synchronous anxiety at 1 year. Using a hierarchical regression, controlling for anxiety at 1 year in block 1, prenatal maternal anxiety significantly predicted restriction at 1 year [R2 = 0.143, F (2, 84) = 7.014, p < 0.01].

Next, participants were identified by the SCOFF as having/not having an eating disorder during pregnancy and at 6 or 12 months postpartum. The descriptive statistics for these two groups are presented in Table 4. Participants identified by the SCOFF as potentially having an eating disorder at any time-point did not have infants with significantly different weights and did not report significantly different use of pressure to eat or restriction at 1 year. Moreover, separate classifications according to the SCOFF during pregnancy and at 6 months and 12 months postpartum also failed to yield significant differences for child weight, maternal restriction, and pressure to eat.

Table 4. . Descriptive statistics for women identified as potentially having or not having an eating disorder during pregnancy or at 6 or 12 months postpartum
 Eating disorder (N = 22)No eating disorder (N = 65)Student's t value
  1. The classification of eating disorder included women who were classified by the SCOFF as potentially having an eating disorder during pregnancy or at 6 or 12 months postpartum. NS, not significant.

Infant weight z score [mean (SD)]0.492 (0.835)−0.130 (0.884)−2.892 (NS)
CFQ: pressure to eat [mean (SD)]2.136 (0.885)2.28 (0.950)0.610 (NS)
CFQ: restriction [mean (SD)]2.631 (0.791)2.45 (0.756)−0.937 (NS)

Discussion

  1. Top of page
  2. Abstract
  3. Introduction
  4. Research Methods and Procedures
  5. Results
  6. Discussion
  7. Acknowledgement
  8. References

The principal aim of this study was to examine the longitudinal relationship between maternal psychopathological symptomatology before the commencement of parenthood and the use of controlling feeding practices in a non-clinical sample of mother-child dyads at 1 year postpartum. Supporting the hypotheses, various aspects of maternal psychopathology during pregnancy and at 6 and 12 months postnatally were significantly correlated with validated maternal reports of controlling feeding practices at 1 year, when controlling for infant weight and length of breast-feeding. In particular, maternal restriction of food at 1 year correlated significantly with maternal anxiety and paranoid ideation during pregnancy, with somatization and anxiety at 6 months, and with obsessive-compulsiveness at 1 year. Importantly, during pregnancy, maternal psychopathology was significantly associated with the later use of controlling feeding practices at 1 year, indicating that the presence of prenatal maternal mental health symptomatology may predispose women to use more restrictive feeding practices at 1 year postpartum.

The BSI measures various aspects of mental health symptomatology, but the variables that correlated with controlling feeding practices were anxiety, obsessive-compulsiveness, paranoid ideation, and somatization. These variables can all be perceived as subtypes of anxious psychopathology. Although previous research has documented a relationship between maternal anxiety and the presence of child feeding problems (17,18,35), to our knowledge, this is the first study to indicate that maternal anxiety is associated with restriction over child feeding. Recently, anxiety disorders have been documented as particularly common during pregnancy and the puerperium (36). The expression of anxiety around feeding and food at this early stage may classically condition the child to find feeding an anxious and aversive experience in itself, leading to food refusal and subsequent fussiness that may encourage parental control or restriction of preferred foods. The ideal feeding environment is one that asserts control to the child, particularly during the late infancy period when children are learning to feed and take pleasure in self-feeding and selecting foods. This period can be slow and messy, and mothers with high anxiety or obsessive-compulsive tendencies may find it distressing and feel compelled to control, leading to a vicious cycle of negative interaction. High levels of anxiety may also impede maternal ability to interpret child hunger and satiety signals, which may evoke the use of controlling or restrictive feeding techniques, interfering with the mother's belief that the child will self-monitor. Future research should evaluate this seemingly important role of maternal anxiety in the development of aversive feeding practices.

Contrary to the hypotheses, the results of this study failed to replicate previous research that has found that maternal eating psychopathology is associated with the use of controlling feeding practices. This finding may reflect the non-clinical nature of this sample, although ∼18% of the sample was classified by the SCOFF as potentially having an eating disorder at 6 months postpartum. It is important to note that the SCOFF does not provide 100% sensitivity to assess all eating disorder psychopathology; as such, many women may have been misclassified using this measurement. Moreover, although established as measuring the presence of overt eating psychopathology, the brevity of the SCOFF may render it insensitive to the more subtle aspects of disordered eating that are common in a normal population of women. As such, these results are not conclusive evidence that maternal eating psychopathology does not predict maternal use of control and restriction when feeding, and further research, using more detailed measures of eating disorders, is necessary to explore the relationship between these variables in more detail. Interestingly, maternal depression also failed to significantly correlate with maternal use of controlling feeding practices at 1 year. Although depression is likely to interfere with the use of sensitive feeding practices, which may lead to control around feeding (37), depression is also associated with withdrawn maternal behavior, which may inhibit the use of controlling feeding practices (38).

In conclusion, although a wealth of previous research has associated maternal psychopathology with child feeding problems, which have been associated with controlling feeding practices, due to a paucity of longitudinal and observational data, the direction and reliability of these relationships remain in question. The use of a longitudinal and observational study here adds to our understanding of this phenomenon by indicating that maternal anxious psychopathology during pregnancy preceded the development of controlling feeding practices at 1 year, whereas maternal depression and eating psychopathology as measured by the SCOFF were not significantly associated with the use of maternal control over feeding. Future research should explore the impact of clinical levels of anxiety on the use of these detrimental controlling feeding practices.

Footnotes
  • 1

    Nonstandard abbreviations: BSI, Brief Symptoms Inventory; SCOFF, acronym for eating disorder measure; CFQ, Child Feeding Questionnaire; FIS, Feeding Interaction Scale.

References

  1. Top of page
  2. Abstract
  3. Introduction
  4. Research Methods and Procedures
  5. Results
  6. Discussion
  7. Acknowledgement
  8. References
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