Parents with Eating Disorders

An Intervention Guide

Shiri Sadeh-Sharvit, James Lock

• Publisher: Routledge
• Year: 2018
• Print ISBN: 9781138293489
• eBook ISBN: 9781351859240
• Topic: Psychology
• Subtopic: Abnormal Psychology
• Index: Psychology

This groundbreaking volume presents a new conceptual approach to treating adults with eating disorders and their children. By utilizing Parent-Based Prevention, a state-of-the-art intervention program from Stanford University for families who risk raising children in the context of parental eating disorders, Parents with Eating Disorders offers a practical, evidence-based manual to working with affected families with the goal of preventing disordered eating from being passed to future generations. Additional resources include intervention planning and self-assessment forms intended for clinicians to use as they implement the program.

1    Introduction

What is the Parent-Based Prevention of Eating Disorders?

Parent-Based Prevention of eating disorders is a manualized preventive intervention program designed to support parents with eating disorder histories so that their children develop healthy eating behaviors. Parent-Based Prevention encourages healthy feeding, eating, and self-regulation patterns in children, effective parental communication, and enhanced parental collaboration in order to promote healthy lifestyles and resilience in their children. The intervention is geared toward improving parental competence and self-efficacy through psychoeducation, coaching about behavioral changes, and differentiation between age-appropriate experiences and the potential adverse effects of parental eating disorders on child outcomes. It is composed of conjoint meetings with both parents, one family meal assessment, and meetings held with the affected parent alone.

Structure of Parent-Based Prevention

Parent-Based Prevention is delivered over the course of sixteen weeks and is composed of three phases:

•    Phase One: Setting up joint goals.

•    Phase Two: Distinguishing the parental eating disorder from parental functioning.

•    Phase Three: Enhancing parental efficacy and family resilience.

The sequence of the meetings in Parent-Based Prevention reflects its nature as a personalized program that integrates the needs of parents with young children, and a focus on the affected parent as well as their partner and children. During Phase One and Phase Three, both parents take part in the meetings, while in most sessions in Phase Two, only the affected parent – that is, the parent with the eating disorder of the history of one – meets with the therapist. In the first two phases (i.e., the first eight meetings), sessions are scheduled on a weekly basis, and they are followed by four sessions in Phase Three that are held fortnightly. Each meeting begins with setting an agenda for the meeting: reviewing any changes at home, insights that the parents have developed, or related topics that they have identified from the time of the last meeting with the therapist. Sessions 3–12 always conclude with the parents deciding on at least one specific behavioral experiment they want to try at home and which will be evaluated in the consecutive session. A “behavioral experiment” is the term to describe specific actions the parents will test at home, that are aimed at reducing problematic behaviors related to feeding their child that the parents feel need to address during the program. These behaviors may be focused on changing behaviors in the parents or the child. Parents are advised to test their attempted change, and to think of it as an experiment rather than an answer. If the attempted change does not result in the desired outcomes, it will be discussed in the following session, and the behavioral experiment will be refined. After the individual sessions with the affected parent, it is expected that the contents of those sessions will be shared with their partners. In the following session, the therapist explores whether they have communicated with their partners, and if so, regarding what topics. An abridged outline appears in Table 6.1 in Chapter 6.

Purpose and Audience of This Manual

Target Patient Population

This Parent-Based Prevention intervention guide describes an empirically supported program for improving feeding practices, child outcomes, and parental empowerment in families in which a parent has been diagnosed with an eating disorder. An “eating disorder” may be anorexia nervosa, bulimia nervosa, binge-eating disorder, or any other eating disorder, Other Specified Feeding or Eating Disorder (OSFED), or Unspecified Feeding or Eating Disorder (UFED), according to the Diagnostic and Statistical Manual of Mental Disorders (DSM-5) definition (American Psychiatric Association, 2013). This manual was developed to support the families of any parent who has been diagnosed with an eating disorder at any time in their lives, whether they are recovered or still struggling with symptoms. In regard to the language and terms being used, the people involved in the program are not patients in the usual sense. In this approach the target audience are families where a parent has had a current or past eating disorder, who are experiencing challenges in feeding their young children, and are interested in minimizing the impact of their concerns and habits regarding eating, food, shape, and weight on their children. The children are not best considered to be patients either; rather, their healthy development and wellbeing is at the center of the program. Thus, the aim of the program is to promote resilience and wellbeing rather than being focused on pathology.

Clinician Qualifications

The clinician delivering this preventive intervention should be a trained therapist and is referred to as such. This manual is intended for clinicians who have been trained and gained experience in: (a) psychotherapeutic interventions with patients with eating disorders, and (b) developmental psychology and parental counseling. The therapists that are most suitable to provide the preventive intervention program presented in this manual are those who have worked with patients with eating disorders and who are familiar with how eating disorders behaviors and thoughts impact the affected individual’s life. They should also feel confident in their ability to facilitate changes in the family via parental and couple counseling. Therapists intending to utilize this guide should feel comfortable in their ability to deliver Parent-Based Prevention according to the guidelines and instruction given hereafter, and should be willing to broaden their theoretical knowledge by reading additional references when needed. In general, treatment of individuals with eating disorders should be carried out with additional professional supervision and consultation depending on the clinician’s experience.

Reference

American Psychiatric Association. (2013). Diagnostic and statistical manual of mental disorders (5th ed.). Arlington, VA: American Psychiatric Publishing.

2 Understanding the Risks for the Offspring of Parents with Eating Disorders

Review of the Literature: Parental Eating Disorders

The gender distribution of eating disorders is greatly skewed toward females (Hoek, 2006). Furthermore, although gender roles have changed in the Western world, mothers typically assume greater responsibility for feeding their children in the first months of life, and they tend to spend much more time than their spouses with young children (Blissett, Meyer, & Haycraft, 2006). As a result, research has focused primarily on mothers with eating disorders. However, while there is scant data on fathers, several studies suggest that fathers’ eating disorder psychopathology is associated with comparable impacts on their offspring’s eating-related cognitions and behaviors (Lydecker & Grilo, 2016). Given the nature of the current literature, this chapter will focus mostly on mothers with eating disorder histories. We will acknowledge throughout this chapter research findings and theoretical conceptualizations that are relevant to parents of all sexes.

Children’s development may be compromised by parental mental disorders. The nature and extent of parental symptoms correlate with those of their offspring (Kim-Cohen et al., 2006). Research shows that 5 to 10 percent of women have an eating disorder at some point of their lives (Hoek & van Hoeken, 2003; Hudson, Hiripi, Pope Jr., & Kessler, 2007), and at least 16 percent of these women become mothers (Maxwell et al., 2011). Given an average of 1.5–2 children per family in Europe and the United States, respectively, it is suggested that at least 1.5 million preschool children are raised in the context of a maternal eating disorder (Bloom & Sousa-Poza, 2010; Cherlin, 2010; Howden & Meyer, 2010). The offspring of mothers with eating disorders have greater difficulties in self-regulation of their eating and emotional functioning than the children of mothers who do not have eating disorders (Micali, 2005).

The Feeding Relationship

The offspring of mothers with a history of an eating disorder are at an increased risk for feeding and eating problems, as well as other developmental, behavioral, and emotional difficulties (Agras, Hammer, & McNicholas, 1999; Micali, 2005; Zerwas et al., 2012). In particular, the development of healthy eating habits appears to be significantly compromised in these children. Evidence suggests that certain aspects of the maternal eating disorder play a distinct role in different developmental stages. As early as six months of age, infants of mothers with anorexia nervosa present more feeding problems. By age four, their mothers report greater child emotional eating (de Barse et al., 2015). The infants of mothers with bulimia nervosa are more likely to be overweight for their age and have more difficulties transitioning to solid foods as compared to children of mothers without an eating disorder (Agras et al., 1999). Notably, the more severe the maternal eating disorder symptoms are, the more controlling her feeding practices are (Stein et al., 2001). However, for toddlers and older children, most aspects of feeding and eating do not appear to be related to a specific maternal eating disorder diagnosis. The infants of mothers with lifetime eating disorders exhibit less positive affect with their mothers during feeding interactions (Stein, Woolley, Cooper, & Fairburn, 1994). Elementary-school children whose mothers have lifetime eating disorders are more likely to have “health-conscious” eating habits (Ammaniti, Lucarelli, Cimino, D’Olimpio, & Chatoor, 2012; Easter et al., 2013; Micali, Simonoff, Stahl, & Treasure, 2011), and by age thirteen they report greater disordered eating and emotional eating as compared to children whose mothers do not have histories of eating disorders (Allen, Gibson, McLean, Davis, & Byrne, 2014).

During early childhood, parents are directly responsible for the food that is offered, the amount that is provided, the timing and context of meals, and who is involved in feeding interactions (Danaher, Fredericks, Bryson, Agras, & Ritchie, 2011; Rapoport & Bourdais, 2008). When parents have histories of eating disorders, these feeding-related decisions become more challenging and stressful (Mazzeo, Zucker, Gerke, Mitchell, & Bulik, 2005). For example, parents with eating disorders are more worried about their children’s weight (Sadeh-Sharvit et al., 2015). As a result, they tend to report greater controlling behaviors (Blissett & Haycraft, 2011; Hodes, Timimi, & Robinson, 1997; Hoffman et al., 2013). Of note, maternal concerns regarding child nutrition, feeding and weight were reported as more intense in regard to daughters (Sadeh-Sharvit et al., 2015).

Analyses of recorded feeding interactions of mothers with eating disorders and their children generally revealed increased conflicts, stricter control over children’s eating, and more maternal negative emotions in comparison to non-symptomatic dyads (Haycraft & Blissett, 2010; Park, Senior, & Stein, 2003). However, these findings were not replicated in all reports (Hoffman et al., 2013). In addition, these mothers use food more frequently than other mothers for non-nutritional purposes, such as soothing or distracting the child (Agras et al., 1999; Evans & Le Grange, 1995). They also reported rarity of family meals (Sadeh-Sharvit et al., 2015). Furthermore, mothers with eating disorders also express concerns about their children’s awareness of the maternal eating disorder. Importantly, these parents have many dilemmas about the ways to promote healthy eating patterns in their children and are motivated to receive help themselves. Many of these women said they felt they had no one to consult regarding the aforementioned issues. This manual addresses this gap that has been noted by clients, professionals, and stakeholders alike (Little & Lowkes, 2000).

Children’s Cognitive Development

Insufficient feeding, primarily during early childhood, may be related to the delayed developmental functioning found in the young children of mothers with an eating disorder history. As infants, they have lower body weight and head circumference, and lower verbal functioning compared to children of mothers with no eating psychopathology (Koubaa, Hällström, Hagenäs, & Hirschberg, 2013). There is evidence that toddlers of mothers with eating disorder psychopathology show delayed mental and psychomotor development, in comparison to peers with no maternal eating disorder history (Sadeh-Sharvit, Levy-Shiff, & Lock, 2015). Lower global intellectual abilities, motor skills, and social reasoning were found in the toddlers of mothers with anorexia nervosa, which is inherently characterized by restrictive eating (Kothari, Rosinska, Treasure, & Micali, 2014). When evaluated a couple of years later, these children had higher IQ scores and better working memory, but reduced control of attention, as compared to children whose mothers had bulimia nervosa or no eating disorder (Kothari, Solmi, Treasure, & Micali, 2013). It is possible that maternal eating disorder symptoms are more strongly associated with greater feeding and eating problems in younger children (Squires, Lalanne, Murday, Simoglou, & Vaivre-Douret, 2014; Stein, Woolley, & McPherson, 1999). Older children may be less affected because they are exposed to more diverse eating experiences outside of the home milieu. Thus, the maternal eating disorder may play a smaller role in older children’s caloric intake, which results in a decrease in the extent of developmental delay over time.

Broader Maternal and Child Wellbeing

Maternal eating disorders are also linked to a wide range of adverse maternal and child behaviors beyond those associated with eating. Mothers with eating disorders rate their children as presenting more volatile temperaments (Zerwas et al., 2012), less positive emotions, and greater behavioral symptoms than children of mothers with no eating psychopathology (Cimino, Cerniglia, Paciello, & Sinesi, 2013; Micali, De Stavola, Ploubidis, Simonoff, & Treasure, 2014). These mothers also report higher parenting-related stress a...

Table of contents

• Cover Page
• Half Title
• Title Page
• Copyright Page
• Table of Contents
• Acknowledgments
• 1 Introduction
• 2 Understanding the Risks for the Offspring of Parents with Eating Disorders
• 3 The Broader Context of the Transition to Parenthood in Adults with Eating Disorders and Their Partners
• 4 The Development of Typical and Atypical Feeding and Eating Processes in Children and Youth
• 5 Two Families Seeking Help
• 6 Overview of Parent-Based Prevention
• 7 Adapting Parent-Based Prevention to Diverse Family Structures and Backgrounds
• 8 Treatment Planning and Real-Time Evaluation Using Assessment Tools
• 9 Phase One: Setting Up Joint Goals
• 10 Session 1: Gearing Up
• 11 Session 2: The Family Meal
• 12 Session 3: Embracing Change
• 13 Phase Two: Distinguishing the Parental Eating Disorder from Parental Functioning
• 14 Sessions 4–5, 7–8: Individual Sessions with the Affected Parent
• 15 Session 6: A Conjoint Meeting with Both Parents
• 16 Phase Three: Enhancing Parental Efficacy and Family Resilience
• 17 Parent-Based Prevention in Action: Stacey and Rob
• 18 Parent-Based Prevention in Action: Dave and Gabby
• Index