a six-year prospective study on children of mothers with eating disorders- the role of paternal...

European Eating Disorders Review

A six-year prospective study on children of mothers with eating disorders: the role of paternal psychological profiles.

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European Eating Disorders Review ERV-BRI-2012-03-0450.R3 Special Issue n/a Cimino, Silvia; Sapienza University of Rome, Department of Dinamic and Clinic Psychology Cerniglia, Luca; Uninettuno International Telematic University, Paciello, Marinella; Uninettuno International Telematic University, sinesi, stefania; Sapienza University of Rome, outcome, risk factors, childhood, development Background: Several studies have suggested that maternal eating disorders (EDs) represent a significant risk factor for children's affective and behavioral development. Yet, little emphasis has been placed on the paternal role. Objectives: The present longitudinal study aimed to clarify the role of maternal EDs and the influence of paternal psychological profiles on children's emotional development. Method: Our sample was composed of N=64 families with firstborn children selected through preschools, primary schools, and outpatient clinics in central Italy. Parents and children participated in a 6-year longitudinal protocol that included a diagnostic interview conducted by clinicians (Structured Clinical Interview for DSM-IV Axis I Disorders [SCID-I]), a self-report (Symptom Checklist-90-Revised [SCL-90-R]), and a parental report-form questionnaire (Child Behavior Checklist [CBCL]). Results: The influence of mothers' EDs on their children's emotional development was confirmed. Moreover, fathers' anxiety and obsessive-compulsive problems in association with mothers' EDs and depressive symptoms influenced the onset of both internalizing and externalizing difficulties in their children over time. Conclusion: Our results suggest that fathers' psychopathological risk affects the development of emotional problems in children with mothers who have E D s.

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Body: @@date to be populated upon sending@@ Dear Dr. Cimino: It is a pleasure to accept your manuscript entitled "A six-year prospective study on children of mothers with eating disorders: the role of paternal psychological profiles." in its current form for publication in European Eating Disorders Review. As agreed, Tables 4-9 will be published under supplementary data just online. If you have not done so already you should now supply your completed Copyright form, located at http://media.wiley.com/assets/1540/86/ctaaglobal.pdf Thank you for your fine contribution. On behalf of the Editors of European Eating Disorders Review, we look forward to your continued contributions to the Journal. Sincerely, Prof. Fernando Fernández-Aranda Editor in Chief, European Eating Disorders Review [email protected]

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of 26 European Eating Disorders Review

A six-year prospective study on children of mothers with eating disorders: the role of

paternal psychological profiles.

Cimino Silvia*, Cerniglia Luca**, Paciello Marinella**, Sinesi Stefania*

*Department of Dynamic and Clinical Psychology Faculty of Medicine and Psychology Sapienza University of Rome Via dei Marsi n. 78 00185 Rome +39 06 97997735; +39 338-3080680 e-mail: [email protected]; [email protected]

** Uninettuno Telematic International University

Corso Vittorio Emanuele n. 39 00186 Rome

European Eating Disorders Review Page 2 of 26

Abstract Background: Several studies have suggested that maternal eating disorders (EDs) represent a significant risk factor for children's affective and behavioral development. Yet, little emphasis has been placed on the paternal role. Objectives: The present longitudinal study aimed to clarify the role of maternal EDs and the influence of paternal psychological profiles on children's emotional development. Method: Our sample was composed of N=64 families with firstborn children selected through preschools, primary schools, and outpatient clinics in central Italy. Parents and children participated in a 6-year longitudinal protocol that included a diagnostic interview conducted by clinicians (Structured Clinical Interview for DSM-IV Axis I Disorders [SCID-I]), a self-report (Symptom Checklist-90-Revised [SCL-90-R]), and a parental report-form questionnaire (Child Behavior Checklist [CBCL]). Results: The influence of mothers' EDs on their children's emotional development was confirmed. Moreover, fathers' anxiety and obsessive-compulsive problems in association with mothers' EDs and depressive symptoms influenced the onset of both internalizing and externalizing difficulties in their children over time. Conclusion: Our results suggest that fathers' psychopathological risk affects the development of emotional problems in children with mothers who have EDs.

Key words: maternal eating disorders, paternal psychopathological risk, longitudinal study.


Introduction and aims

The international scientific literature points to maternal psychopathology as a crucial risk factor

for the development and maintenance of emotional and behavioral problems in children (Cox & Barton, 2010). In particular, studies have focused on the influence of maternal depression on internalizing problems in children and, more recently, on the impact of maternal eating disorders (EDs) on children's mental health (Bagner, Pettit, Lewinsohn & Seeley, 2010; Watkins, Cooper & Lask, 2012).

Various studies have examined food refusal behaviors and weight faltering in children of

mothers with EDs. The resultant empirical and clinical research findings have led many authors to suggest that children's feeding disorders are associated with mothers' EDs. Notably, compared to children of women without an ED, children of women suffering from EDs have been reported to show a three-fold increase in the risk of manifesting feeding problems in the first years of life (Micali, Simonoff, Stahl & Treasure, 2011). Furthermore, the presence of EDs in mothers may predict infants' poor physical growth and an early onset of feeding disorders (Ammaniti, Lucarelli, Cimino, D'Olimpio & Chatoor, 2012).

A limited number of studies have examined whether maternal EDs affect children's emotional

development. An association was found between mothers EDs and negative outcomes on the emotional functioning in their children (e.g. aggressive and oppositional behaviors). Empirical and clinical studies point out that the children of women suffering from EDs show a higher risk of manifesting maladaptive emotional and behavioral functioning in their first years of life if compared to healthy controls (Whelan and Cooper, 2000) Moreover, mothers with EDs have been shown to be more likely to have hard to handle, irritable, and unfriendly children, suggesting that the presence of maternal EDs may impede the building of adaptive interactional exchanges in caregiving contexts (Zerwas et al., 2012).

While most studies in this field have dealt preeminently with maternal EDs and their influence

on children, fathers' psychological profiles, which may represent a significant risk and/or protective


factor, have received relatively little attention. The limited research examining paternal psychopathology thus far has suggested that it may play a crucial role in the quality of caregiving, modulating and integrating with interactional mother-infant patterns. In particular, a father with psychopathologic symptoms that shows a low level of responsiveness to his children may be a risk factor for the onset of children's maladaptive behavior (Elgar, Mills & McGrath, 2007). Indeed, it has been proposed that a combination of maternal and paternal psychopathologies may create a style of co-parenting dominated by negative interactive cycles with the children (Pinquart & Teubert, 2010). Interestingly, Fassino, Amianto, and Abbate-Daga (2009) suggested that this association between parents' psychopathological symptoms and children's EDs may remain stable over time. On the other hand, adaptive paternal psychological functioning could facilitate mothers' understanding of their children's needs and thereby may serve as a protective factor against the development of psychopathologies in children (Cooper, Whelan, Woolgar, Morrell, Murray, 2004). However, there is a dearth of information in the scientific literature related to the father's role as a potential risk or protective factor.

Based on the above theoretical foundations, the present longitudinal study aimed to further

elaborate on the impact maternal EDs on children's emotional functioning from infancy through early childhood, including a close examination of the influence of paternal psychological profiles. Our study had the following three specific objectives:

1) To evaluate mothers' and fathers' psychological profiles longitudinally in a sample of families

with women who have EDs and in a control group;

2) To evaluate the children's emotional/adaptive profiles in the clinical and non-clinical samples

over time;

3) To elucidate the role of maternal EDs, the effect of maternal psychological profiles, and the

influence of paternal psychological profiles on children's emotional development.

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Methodology Study design and sample

A 6-year longitudinal study was conducted with three serial assessments. The initial assessment

(T1) was administered face-to-face over a period of one year by a group of trained psychologists who visited the families in their homes. The second assessment (T2) was administered 3 years after T1, and the third assessment (T3) was administered 3 years after T2. During the T1 assessment, we administered all sections of the Structured Clinical Interview for DSM-IV Axis I Disorders (SCID-I, non-patient version) to the mothers (First, Spitzer, Gibbon, Williams, 1997).

A total of 297 families were recruited from preschools, primary schools, and outpatient clinics in

central Italy. The study sample was divided into two subgroups: families in which the mothers suffered from an ED (with no Axis I comorbidity) constituted the clinical group (CG; N = 35); and families in which the mothers received no diagnosis constituted the non-clinical group (NCG; N = 201). Families in which the mothers received a diagnosis other than ED were excluded at T1 (dysthymic disorder, N=15; substance dependence, N=3; social phobia, N=5; Axis I comorbidity, N=7). An additional N=13 families were eliminated because they were pursuing a psychological treatment, and we wanted to avoid the potential influence of psychotherapeutic or pharmacological intervention on family dynamics. And N=18 families were later excluded from the analysis due to missing data in the interviews.

Consistent with prior prospective studies (Lane, 2008), the drop-off rate at the second assessment

(T2) 3 years after T1, and the third assessment (T3), 3 years after T2, were ~53% and ~62%, respectively. Thus, at T2, we assessed 111 families (N = 31 in CG; N = 80 in NCG) and at T3 we assessed 90 families (N = 31 in CG; N = 59 in NCG). Follow-up data were available for 89% of the CG subjects at T2 and T3 and for 40% of NCG subjects at T2 and 29.5% of NCG subjects at T3.

The CG subjects were paired with NCG subjects by age of the children, age of the mothers, and

the families' socio-economic status. The sample presented for this study therefore included N=64 families with firstborn children (N=31 in CG; N=33 in NCG). In the CG, about half of the mothers


(16/31) suffered from anorexia nervosa and about half (15/31) suffered from bulimia nervosa. Most of these mothers (87%) had a documented clinical history of their EDs with a diagnosis in their early adulthood using the SCID-I (non-patient version). These diagnoses were confirmed at T1 in our study.

Demographic data

In both the CG and NCG, all parents were Caucasian and most (87%) were of middle socio-

economic status (SES; Hollingsead, 1975). A majority (68%) of the parents lived together; 89% of the fathers and 71% of the mothers were employed; 82% of the children went to preschool or kindergarten. Most (86%) of the children had been breast-fed. All the partners of the mothers recruited for the study were the biological fathers of the children. At T1, the mean age of the mothers was 33.2 years (standard deviation [sd] = 3.1) and the mean age of the fathers was 35.3 years (sd = 2.5). The children in both groups were 50% males and 50% females. The children had a mean age of 2.4 years (sd = 0.4) at T1, 5.3 years (sd = 0,5) at T2, and 7.6 years (sd = 0.4) at T3.

Tools and procedures

All parents signed an informed consent for all the procedures. The mothers and the fathers each

completed the Symptom Checklist-90-Revised (SCL-90-R) and the Child Behavior Checklist (CBCL), described below, at T1, T2 and T3 independently.

The SCL-90-R is a 90-item self-report symptom inventory aimed to measure psychological

symptoms and psychological distress (Derogatis, 1994). Its main symptom dimensions are Somatization, Obsessive-Compulsivity, Interpersonal Sensitivity, Depression, Anxiety, Hostility, Phobic Anxiety, Paranoid Ideation, and Psychoticism. The SCL-90-R has been shown previously to have good internal coherence (α = 0.70-0.96) in adolescents and adults (Italian validated version - Prunas, Sarno, Preti, Madeddu, Perugini, 2011).

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The CBCL is a questionnaire filled out by parents and caregivers to assess a child's abilities and

his/her specific behavioral/emotional characteristics. The CBCL/1½-5 (Achenbach & Rescorla, 2001) is composed of 100 items. Its Internalizing Problems Scale consists of four subscales: Emotionally Reactive, Anxious/Depressed, Somatic Complaints, and Withdrawn. And its Externalizing Problems Scale is composed of two subscales: Attention Problems and Aggressive Behavior. The CBCL/1½-5 has high test-retest reliability and high internal consistency (Achenbach & Rescorla, 2001). The CBCL/6-18 (Achenbach & Rescorla, 2001) is composed of 113 items. Its

Internalizing Problems Sc al e consists of three subscales: Anxious/Depressed, Withdrawn/Depressed, and Somatic Complaints. And its Externalizing Problems Scale consists of two subscales: Rule-Breaking Behavior and Aggressive Behavior. The criterion-related validity of both versions of the CBCL is supported by the ability of the CBCL's quantitative scale scores to discriminate between demographically matched, referred and non-referred children (Kim et al., 2012). In the present study, we used the Italian validated versions and the Italian cut-off values (Frigerio & Montirosso, 2002).

Statistical analysis

As a preliminary step, the normality of variables was determined and intra-group correlations

were assessed to control for the independency of the relationships between mothers' and fathers' dimensions in the GC and NCG. Descriptive analyses demonstrated that all variables were normally distributed. Correlational analyses showed that, in both groups, the relations between mothers' and fathers' SCL-90-R dimensions were not significantly or slightly related (<.30) whereas the mothers' and fathers' CBCL evaluations correlated significantly and strongly (>.30). Thus, for comparison of SCL-90-R dimensions, we considered the mothers' and fathers' scores within each group to be independent, whereas for the children's dimensions, we aggregated the mothers' and fathers' CBCL dimensions as mean scores for each child.


We began our analyses by examining fluctuations over time in parental dimensions of SCL-90-

R, separately for each group. Specifically, we examined mean scores from Time 1 to Time 3 on each SCL-90-R parental dimension by performing repeated measure analyses of variance, using Time as a within-subject factor and Group as a between subject factor. Then, analyses of variance (ANOVA) were used to test significant differences between CG and NCG on parental SCL-90-R dimensions and CBCL dimensions, separately for each time of assessment. Finally, a series of regression analyses were conducted to examine the influence of specific SCL-90-R dimensions related to eating disorder at Time 1 on three specific child's specific emotional/adaptive and, in general, on internalizing and externalizing outcomes from Time 1 to Time 3. The specific SCL-90- R dimensions and child outcomes were selected based on empirical literature (Ammaniti et al., 2012; Frigerio & Montirosso, 2004). In all regression models the belonging to clinical/non clinical group and gender were entered at Step 1, the maternal dimensions at Time 1 were entered at Step 2, the paternal dimensions at Time 1 were entered at Step 3, the interaction between some specific mothers' and fathers' dimensions related to eating disorder were entered at Step 4.

All analyses were performed with SPSS software (version 15.0).

Results Stability and change of parents' psychological SCL-90-R dimensions

As shown in Table 1, mothers in the CG had higher scores than mothers in the NCG on all

SCL90-R dimensions over time. Fathers in the CG had higher scores than fathers in the NCG on all dimensions at T1 and T3, but not at T2 (Table 2). At T2, fathers' SCL-90-R dimension scores differed significantly between the groups only on the obsessive-compulsive, anxiety, and psychoticism subscales.

Page 8 of 26


The mothers' scores on SCL-90-R dimensions were all stable over time. They showed one

significant interaction between time point and group on depression (F2,57 = 3.64; p < .05; Wilks Lambda = .88). Means tended to increase over time for the CG, but remained stable for the NCG. The fathers' SCL-90-R results indicated that interpersonal sensitivity and phobic anxiety were stable over time, whereas obsessive-compulsive (F2,57 = 13.32; p < .01; Wilks' Lambda = .68), somatization (F2,57 = 4.93; p < .01; Wilks' Lambda = .88), hostility (F2,57 = 3.66; p < .05; Wilks' Lambda = .88), anxiety (F2,57 = 9.66; p < .01; Wilks' Lambda = .75), depression (F2,57 = 3.42; p < .05; Wilks' Lambda = .89), paranoid ideation (F2,57 = 3,10; p < .05; Wilks' Lambda = .90], and psychoticism (F2,57 = 6.52; p < .01; Wilks' Lambda = .81) changed significantly over time. Mean scores followed a quadratic trend with a decline from T1 to T2, and an increase from T2 to T3. There were significant interactions between time point and group on somatization (F2,57 = 5.01; p < .01; Wilks' Lambda = .85), depression (F2,57 = 3.02; p < .05; Wilks' Lambda = .90), hostility (F2,57 = 4.40; p < .01; Wilks' Lambda = .86), paranoid ideation (F2,57 = 3.93; p < .05; Wilks' Lambda = .87). For these dimensions, CG mean scores followed a quadratic trend, whereas NCG mean scores remained stable and low. Nevertheless, in the CG, fathers' scores on the obsessive-compulsive, anxiety, phobic anxiety, and psychoticism subscales exceeded the cut-offs for the Italian population at all three time points.


Children's longitudinal profiles: differences between the CG and the NCG

The emotional-adaptive profiles of children in the CG had significantly higher scores than those

of children in the NCG on all CBCL dimensions at all three assessment time points (Table 3).

Predictive power of maternal EDs and of mothers' and fathers' psychological profiles on children's specific emotional/adaptive outcomes

All regression model results showed that belonging to the CG significantly predicted the child's

outcomes, explaining 22-82% of the variance (Tables 4-9). In particular, mothers' somatization contributed significantly to explaining higher scores for children in the aggressive behavior and externalizing problems subscales at all assessment time points as well as in the withdrawal/depression subscale at T3. The mothers' psychoticism score was related to the children's anxiety/depression subscale scores at T1 and T2. Meanwhile, obsessive-compulsive symptoms revealed in the fathers' SCL-90-R subscales were related to children's internalizing scores at T1. Moreover, fathers' anxiety subscale scores contributed significantly to explaining higher scores for children on the subscales of anxiety/depression, aggressive behavior, and both externalizing and internalizing problems at T3.

Page 10 of 26


An interaction between maternal depression and paternal obsessive-compulsive dimensions

contributed significantly to explaining children's both externalizing and internalizing outcomes at all time points except for the externalizing behaviors at T2. Negative beta coefficients in regression models are explained by suppression effects, as evidenced by positive correlations between independent and dependent variables. With the exception of gender, all dimensions were highly and significantly correlated (p < .001).

Discussion

Several interesting issues emerge from our results. First, our study indicates that mothers in the

CG had higher psychopathological risk in their psychological profiles than mothers in the NCG at all assessment time points. These scores were stable over time, with the exception of depressive symptoms in mothers in the CG, who showed a tendency for a linear increase from T1 to T3. Our results are consistent with the literature in indicating that maternal EDs are often associated with depressive symptoms that tend to persist over time, leading to a higher psychopathological risk in this area if left untreated (Bagner et al., 2010; Micali et al. 2011). We further found that fathers in the CG had higher psychopathological risk than fathers in the NCG over the course of the study.


Although we observed a decrease in the scores at T2, several subscales exceeded the cut-offs for the Italian population at T2 as well, suggesting an essentially stable psychopathological risk in some areas within a complex and variable configuration.

Regarding our second objective, children in the CG showed a compromised emotional profile at

all of the assessment sessions. This finding fits well with other studies indicating that maternal EDs may constitute a relevant risk factor for maladaptive functioning in children (Cooper et al., 2004). Children of women with EDs have been described in the international literature as oppositional, aggressive, withdrawn, and showing severe anxiety and depressive symptoms (Dietz et al. 2009; Watkins et al., 2012). Consistent with the results of Patel, Wheatcroft, Park, and Stein (2002), we found that maternal psychopathology, namely the ED, is the crucial issue that influenced children's maladaptive functioning at all assessment time points. The specific characteristics of somatization in the mothers' psychological profiles seem to predict withdrawal/depression, aggressive behavior, and externalizing problems in children. This result is consistent with several studies that have suggested that somatization may be considered a typical issue in the clinical profile of women with EDs (Peñas-Lledó, Vaz Leal, Waller, 2002).

Moreover mothers' psychoticism affected children's anxiety/depression subscales at both Time 1

and Time 2. This result is coherent with the study of Riahi, Amini and Salehi Veisi, (2010), that points out the effect of mothers' psychoticism symptoms on internalizing behaviors of their children.

Interestingly, our data further suggest that specific paternal psychological profiles, particularly

anxiety and obsessive/compulsive symptoms, may predict problematic issues in a child's global functioning, both in internalizing and externalizing areas. Consistent with the present findings, Dietz, Jennings, Kelley, and Marshal (2009) have provided empirical evidence of the presence of psychopathologic symptoms in the partners of women with EDs that can facilitate the onset of emotional disorders in their children.

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Finally, it is interesting that maternal depressive symptoms only influenced maladaptive

functioning of children in the CG when paternal obsessive-compulsive symptoms were present. This finding supports prior findings by Dietz et al. (2009) and Bagner et al. (2010) showing that adverse outcomes in children exposed to maternal depressive symptoms are also dependent upon the presence of paternal psychopathological risk.

Strengths and limitations

This study addressed the relatively unexplored topic of the role of fathers' psychopathological

risk in the outcome of children of mothers with EDs, and in the emergence of psychological disturbances in these children. We employed a longitudinal design with a matched control group and all of the measures used had been well validated previously.

Our work has some limitations. Firstly, we did not administer the SCID-II to assess personality

disorders in the mothers and we did not evaluate the severity of the mothers' EDs with a specific tool. Subjects in the NCG were paired post hoc with subjects in the CG, and N=26 families in the NCG were not included in our analysis. These limitations will constitute a motivation to continue our research, also taking into consideration samples of mothers with comorbidities including a diagnosis of clinical depression.

Conclusions and clinical implications

The key feature of the present study is the focus on the role of paternal psychological profiles on

children's maladaptive functioning in a sample of families of mothers with EDs. This study has its most significant implications in the planning of assessment protocols for mothers with EDs, which we suggest should consider the role of the partner. Consistent with the findings of Sarkadi, Kristiansson, Oberklaid, and Bremberg (2008), our data reinforce the importance of longitudinal studies that take into consideration the possible fluctuation of scores in specific areas of


psychopathological risk. This approach could aid in the development of more accurate assessment and intervention protocols.

To help ameliorate negative outcomes of children's emotional development, clinicians should

consider the whole family context, especially when the father shows anxiety in his psychological profile. To this end, we propose that when mothers with EDs are assessed, their partners' psychological profiles should also be assessed to mitigate possible psychopathological outcomes in their children. These empirical conclusions are coherent with the clinical work of Kohut, who emphasized how the disturbances of an individual's Self are always related to a two-fold, severe and continuative failure of that person's mother and father (1971, The Analysis of the Self).

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