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Malnutrition and Dysfunctional Mother-Child Feeding Interactions: Clinical Assessment and Research Implications

Department of Dynamic and Clinical Psychology (M.A., L.L.), University La Sapienza, Clinical Nutrition Service, Rome
Department of Developmental Psychology (S.C.), University La Sapienza, Clinical Nutrition Service, Rome
Pediatric Hospital Bambino Gesù IRCCS (A.M.A.), Rome
Department of Psychology, II University of Naples (F.D’O.), Naples, ITALY

Address reprint requests to: Dr. Loredana Lucarelli, Dipartimento di Psicologia Dinamica e Clinica, Facoltà di Psicologia 1, Università degli Studi di Roma La Sapienza, Via dei Marsi 78 - 00185 Roma, ITALY. E-mail: loredana.lucarelli{at}uniromal.it

	ABSTRACT

TOP ABSTRACT INTRODUCTION MATERIALS AND METHODS RESULTS CONCLUSIONS REFERENCES

 
Objectives: To evaluate the effects of age and the presence of feeding pathologies on the relational modes during meals in a sample of mother-child pairs (n = 333), comparing groups of children in the first three years of life with normal development (ND-group, n = 211) and clinical groups of children who presented a diagnosis of feeding disorder and failure to thrive (FD-group, n = 122), and to show an association between specific symptomatic characteristics of the mother, of the child and the dysfunctional modes of their relationship during meals in a subgroup of mother-child pairs (n = 50), selected at random from the total clinical sample and paired with a control group chosen for this study.

Methods: All mother-child pairs in the sample were observed in twenty-minute video-recordings during a meal, using the procedure of the Feeding Scale in the Italian version. A subgroup of mothers, selected at random from the total clinical sample, and paired with a control group, were given two self-reporting instruments for the evaluation of their psychological symptom status: the Eating Attitude Test and the Symptom Checklist-90-Revised, as well as two instruments for the evaluation of the infant temperament and emotional/behavioral functioning: the Baby and Toddler Behavior Questionnaires (from 1 to 18 months) and the Child Behavior Checklist 1-5 (from 18 to 36 months).

Results: Analysis of variance showed that the FD-group present interactional dysfunctional patterns during feeding and raise higher scores in symptomatic characteristics both of the mother and of the child, compared to ND-group. A set of correlation analyses (Pearson coefficients) showed an association among specific symptomatic characteristics of the mothers (dysfunctional eating attitudes, anxiety, depression, hostility), of their children (in particular, anxiety/depression, somatic complaints and aggressive behavior) and of their dysfunctional relational modes during feeding (p < 0.05).

Conclusions: Our study confirms that analysis of the individual characteristics of the child, of the mother and of their relationship during the development of feeding patterns in the first three years of the child’s life is extremely important in the clinical assessment of early feeding disorders, in order to establish a valid diagnostic methodology and formulate strategies for targeted and effective intervention. Furthermore, the results emphasize the clinical utility of our research in early identification of infants and toddlers at risk for feeding problems.

Key words: early feeding disorders, malnutrition, non-organic failure to thrive, dysfunctional mother-child interactions, feeding scale

	INTRODUCTION

TOP ABSTRACT INTRODUCTION MATERIALS AND METHODS RESULTS CONCLUSIONS REFERENCES

 
Early feeding disturbances are quite frequent in the infant population, affecting around 25% to 35% of children [1–5]. The most serious problems occur when inadequate intake of food results in failure to thrive or growth stunting. Health care professionals are aware that the early years of life are crucial in terms of brain development, in particular for the myelinization of axons and the building of neuronal connections essential in the development of language, motor control and regulation of emotion. Therefore, the brain needs an adequate nutritional intake to carry out optimal development [4, 6–8].

Observations focusing on the evolution of these difficulties are also important. There is evidence that early malnutrition could "program" the body of the infant to develop health problems later on in life. Arterial hypertension and cardiac disease as well as, paradoxically, obesity can appear later, the latter a latent effect that is not well understood, but which manifests itself years after nutritional deprivation [9–12]. Furthermore, clinical linkage of feeding disorders and the failure to thrive syndrome from infancy to adolescence has been observed in longitudinal studies that highlight the fact that feeding disorders may persist through time and be associated with developmental, emotional and behavioral difficulties [2, 13–15].

Regarding the pathogenesis of early feeding disorders, it is estimated that malnutrition and failure to thrive may include both organic and non-organic factors and that only 16 to 30 percent have their origin in an organic disease that might explain growth problems [1,5,16].

Recent research has attempted to identify the role of psychological factors in the origin of infant feeding disorders and the possible correlation with the caregiving environment and transactional experience. In fact, in childhood, feeding represents a fundamental experience for the development of the relationship between mother and child, in which emotional signals and the sharing of affect promote the communication of needs, desires and pleasure as well the stabilization of biological rhythms [17–22].

Micro-analytical observation of films of mother-child interaction during breastfeeding (analyzed in detail, frame by frame) have highlighted how an early shared rhythm is established between the two partners. This "turn-taking" is characterized by the reciprocity of exchanges [23, 24] by which the mother is able to recognize the signs of hunger and satisfaction or the need for the child to pause during sucking. For example, when the child is active and suckling, the mother limits her interaction, observes, supports feeding, and quiets her speech; when, on the other hand, the child is taking a break from feeding, the mother becomes more active, speaks to the child, and caresses the child and smiles at him or her. Feeding thus develops a rhythm and reciprocal adaptation between the newborn and the caregiver, which can be considered an early form of social and affective dialogue [22].

While growing, the child continues to need the support of the caregiver during meals to reinforce his or her "sense of self" with regular and predictable experiences. The child also needs support for his or her developing autonomy, which is expressed in the early years of life through the desire to feed oneself.

Gradually the child’s balancing of attachment to the caregiver and emerging autonomy is mirrored by the parents’ developmental tasks of balancing protective behaviors and "letting go" behaviors, which stimulate feeding self-regulatory abilities, autonomous initiatives and the self-reliance of the child. Therefore, the relationship between the caregiver and the child is characterized by a high degree of coordination and bi-directionality and the exchanges constitute a system of interactive regulation, in which each partner influences and regulates the behavior of the other. These influences include favoring or blocking reciprocal adaptation, protecting from possible risk factors or, on the contrary, transmitting negative influences [20,21,25–27]. Clinical distortions in the relationship may occur when the mother and the child are locked into a rigid stance where empathic communication breaks down and neither partner can understand or cooperate with the emotional or developmental agenda of the other [27–29].

Clinical studies conducted on samples of mothers who presented anxiety, depression, dysfunctional eating attitudes (drive for thinness) and eating disorders (anorexia nervosa, bulimia nervosa) revealed that their children often showed a disturbance of feeding regulation. In particular, a higher frequency of early feeding disorders has been shown when mothers of these samples were unpredictable, more intrusive, coercive and controlling in the feeding context, with difficulties in empathically recognizing the signals of hunger and fullness in the child and of regulating the child’s affective states [1,2,30–34]. Furthermore, studies examining the temperamental and behavioral characteristics of children with feeding disorders recognized that they were unpredictable in their eating and sleeping habits, difficult to console and irritable [3,8,32]; they also showed anxiety during separation from the caregiver, as well as contrary and non-collaborative behavior during meals [2,13]. Empirical evidence in some studies seems to suggest that these children, in contact with mothers who are less sensitive to their affective states and to their requirements, i.e. insecure mothers who measure their competence as a parent in relation to how and how much their child eats, show a higher frequency of dyadic dysfunctional interactions during feeding with respect to the control group [3,32,35].

Starting from these first clinical studies, the need to adopt a "multi-factorial and transactional etiological model" for evaluating and treating early feeding disorders emerged. This model attempts to identify a variety of causes that may lead to negative and difficult mother-infant interactions during feeding. Therefore, it is extremely important to examine the links between the temperamental and emotional/behavioral characteristics of the child and the affective-relational experiences in the caregiving system [1,2,8,36–38].

In this article we present the results of our cross-sectional study, which had the following aims:

1. to evaluate the effects of age and the presence of feeding pathologies on the relational modes during meals in a sample of mother-child pairs, comparing a group of children in the first three years of life with normal development and a clinical group of children who presented a diagnosis of feeding disorder and failure to thrive;
   
2. to show evidence of an association between specific symptomatic characteristics of the mother (dysfunctional eating attitudes, anxiety, depression, hostility) and of the child (difficult manageability, irregularity of the biological rhythms, emotional/behavioral problems) and the dysfunctional modes of the mother-child relationship during meals in a group of mother-child pairs, selected at random from the total clinical sample and paired with a control group chosen for this study.
   

	MATERIALS AND METHODS

TOP ABSTRACT INTRODUCTION MATERIALS AND METHODS RESULTS CONCLUSIONS REFERENCES

 
Subjects
The sample of our cross-sectional sample contained 333 mother-child pairs, of which 211 were pairs of mothers and children with normal development (ND-group) and 122 were pairs of mothers and children with a feeding disorder (FD-group); both groups were subdivided into seven age groups from 1 month to 36 months (Table 1).

The FD-group (42.62% males) was selected in a pediatric hospital on the basis of a clinical and diagnostic evaluation, which excluded the presence of organic causes as the origin of these children’s difficulties in establishing regular feeding rhythms and an intake of adequate amounts of food, identifying non-organic failure to thrive (NOFTT) of light or moderate degree, present in all cases. The diagnosis of Infant Feeding Disorder and non-organic failure to thrive was made on the basis of diagnostic criteria in the Zero-to-Three Classification (National Center for Clinical Infant Programs) [39] and from the "Diagnostic and Statistical Manual of Mental Disorders," 4th ed. (DSM-IV) [40].

The gestational period and the psychomotor development of all the children were in the normal range. Most children in the two groups were breast-fed (ND-group = 78%; FD-group = 74%). In addition, most mothers were married (ND-group = 93%; FD-group = 90%), with one child first-born (ND-group = 81%; FD-group = 76%), and they had obtained college (ND-group = 70%; FD-group = 74%) or professional degrees (ND-group = 15%; FD-group = 13%). Most families were of medium (ND-group = 69%; FD-group = 73%) to medium-high (ND-group = 20%; FD-group = 15%) socioeconomic status (SES).

Procedures and Measures
All mother-child pairs of the sample were observed in twenty-minute video-recordings during a laboratory session from behind a one-way mirror, using the procedure of Feeding Scale/Observational Scale for mother-infant interaction during feeding [41, 42], in the Italian version [43]. The dyads were recorded once during lunch; in order to recreate in the laboratory the feeding experience of mother and child at home, the mother was asked to bring the type of food she usually offered her child at home. During the visit to the laboratory, the research coordinator set up a highchair or small chair at a low table, depending on how the mother preferred to feed her child; the mothers were invited to attempt to behave spontaneously during feeding interactions with their children, just as they generally do in everyday life time.

A subgroup of 50 mothers, selected at random from the general FD-group of children, and a control subgroup of mothers (N = 50), paired for child gender and age, were given two self-reporting instruments for the evaluation of their psychological symptom status: the Eating Attitude Test, EAT-40 [44] and the Symptom Checklist-90-Revised, SCL-90-R [45]. The selected subgroup of 50 mothers of children with feeding disorders and the control group were given the Baby and Toddler Behavior Questionnaires, BBQ-TBQ [46] for children from 1 to 18 months, while mothers of older children, from 18 to 36 months, filled out the Child Behavior Checklist, CBCL/1-5 [47]. Both these instruments were standardized and validated to the specific level of age of the children, and we used them in our research for the evaluation of temperamental dimensions (manageability and regularity in the biological rhythms) and emotional/behavioral functioning of the infants and the young children.

Assessment of Mother-Child Feeding Interactions.
The Feeding Scale-Observational Scale for mother-infant interaction during feeding [41, 42], used for this study in the Italian version [43], measures a wide range of interactive behaviors and identify normal and/or at-risk feeding relational dynamics between mother and child, for ages one month to three years. Because the Feeding Scale is applied to children from 1 to 36 months, there are specific items which address the developmental differences in infant and toddler behavior. For example, the item regarding the behavior - "the child falls asleep and stops feeding" - refers to infants, while the item - "the child pushes away or throws away food" - refers to toddlers. Likewise, some caregiver behavior - "the mother holds the baby stiffly, positions the baby without regard for support" - can be observed in mothers of infants.

Studies carried out for psychometric properties have confirmed satisfactory inter-rater reliability, construct and discriminant validity for the tool [41, 43]. The Scale created for the Italian version has 40 items, representing four subscales: Affective State of the Mother, Interactional Conflict, Food Refusal Behaviors of the Child, Affective State of the Dyad. Each item receives a score on a four point Likert scale (none, a little, pretty much, very much); the sum of the mother’s and the child’s scores indicates the total score for each subscale; thus, a global rating is obtained for each of the four subscales, which is then compared to normative scores.

The observational data were coded by two independent coders, trained to the use of the instrument, who were blind to the diagnostic state of the child. The inter-rater reliability, estimated with the use of intraclass correlation coefficients, was between 0.82 and 0.92 [43]. Discriminant analysis used to assess the ability of the Feeding Scale to predict group membership of ND-group versus FD-group showed correct group classification ranged from 82% to 92% [43].

The subscale Affective State of the Mother - nine items - refers to both the possible difficulties of the caregiver in showing positive affect, such as joy and pleasure, and the frequency and quality of negative affect, such as sadness, distress and emotional detachment; at the same time, it evaluates the mother’s ability to interpret the child’s signals and facilitate reciprocal and empathic exchanges. The higher the number of points in this subscale, the greater the number of difficulties the mother has in expressing positive feelings in the relationship and of correctly reading the communicative signs of the child and tune into them. The subscale Interactional Conflict - 16 items - evaluates both the presence and intensity of exchanges of conflict within the dyad; the overall number of points is high when, for example, the mother forces the child to eat, is not flexible in regulating pauses and turn-taking with the child and directs the meal according to her own emotions and intentions, rather than following the communicative feedback given by signals from the child, while the child shows behaviors of distress and avoidance of feeding exchanges in response to the intrusiveness of the mother. The subscale Food Refusal Behaviors of the Child includes nine items which explore the characteristics of feeding patterns of the child, indicating food refusal, poor nutritional intake and difficult regulation of state, for example irritability and/or hyper-excitability, being easily distracted, opposition and negativity; this subscale also examines non contingent maternal behaviors during feeding exchanges, for example when the mother is not able to share the child’s rhythms and interrupts the meal arbitrarily, causing discomfort to the child. A high number of points indicates a lack of reciprocal adaptation between the two partners and an elevated frequency of food refusal on the part of the child. Finally, the subscale Affective State of the Dyad - six items - evaluates quality of affect in the mother-child relation; a high number of points in this subscale shows a negative involvement in the dyad, in which emotions of anger and hostility prevail; the caregiver does not facilitate autonomous initiatives on the child’s part, due to constant control, carried out during feeding through requests, insistent orders, protests and criticism, and the distress behaviors of the child are intensely reactive and contrary.

Assessment of Mother’s Psychological Symptom Status.
The Eating Attitude Test [44] is a screening instrument for identifying abnormal concerns with eating and weight in the adult population; 40 items are categorized to three subscales: Dieting, Bulimia and Food Preoccupation, Oral Control. A high total score in the EAT-40 reflects dissatisfaction with their body image and desire to be thinner, preoccupation with the negative effect of eating behaviors on shape size and self-control of eating. The EAT-40 has demonstrated a high degree of internal reliability (alpha coefficient from 0.79 to 0.94) and has been validated with adult anorexia nervosa patients, but has also been useful in identifying eating disturbances in non-clinical samples [48, 49, 50]. The Symptom Checklist-90-Revised [45, 51] is a 90-item self-report symptom inventory, which is scored and interpreted in terms of nine primary subscales - Somatization, Obsessive-compulsive, Interpersonal Sensitivity, Depression, Anxiety, Hostility, Phobic Anxiety, Paranoid Ideation, Psychoticism - and three Global Indices of Distress (Global Severity Index, Positive Symptom Distress Index, Positive Symptom Total). This tool is a measure of current, point-in-time, psychological symptom status and high scores in the SCL-90-R subscales may evidence clusters of symptoms associated with specific psychopathological conditions. Furthermore, based on the three Global Indices, the Symptom Checklist indicates the degree of severity and depth of individual psychological distress with respect to the nine measured primary dimensions. Internal consistency coefficients for the nine symptom dimensions of the SCL-90-R were quite satisfactory (alpha coefficient ranging from 0.77 to 0.90) and in several studies across community and psychiatric populations high levels of construct and convergent-discriminant validity have been demonstrated [45].

Assessment of Child Temperament.
The Baby and Toddler Behavior Questionnaires, BBQ-TBQ [46] each measure the same six subscale (Intensity/Activity, Regularity, Approach/Withdrawal, Sensory Sensitivity, Attentiveness, Manageability) of infant temperament in 30 items, rated on 5-step scales, asking the caregiver about specific behaviors in everyday situations. Low versus high scores in the BBQ and TBQ subscales are related to the construct of easy versus difficult infantile temperament. The reliability coefficient alpha for both instruments were considered to be within the range usually found for personality instruments (alpha from 0.51 to 0.77); high validity coefficients were obtained both for the BBQ and TBQ scales. Two infant temperamental subscales were selected for the specific purposes of the present research: Manageability and Regularity Scales. The Manageability Scale is a measure of adaptability behaviors towards stimuli and situations, as shown in everyday life, and evaluates the infant’s negative emotionality or irritability; the Regularity Scale measures rhythm in biologically influenced behaviors, such as sleeping and eating.

Assessment of Child Emotional/Behavioral Functioning.
The Child Behavior Checklist, CBCL/1-5 [47] is a tool for evaluating the behaviors and emotions of children in various areas of their daily adaptation and functioning. The CBCL/1-5 is made up of 99 items that explore various areas: activity, interests, attention, fear, play, interaction with peers and adults, states of anxiety and mood, somatic problems, aggression, response to change and converge to define three syndrome scales: Internalizing, Externalizing, Neither Internalizing Nor Externalizing, which group together seven syndromes. The Internalizing scales include the syndromes Emotionally Reactive, Anxious/Depressed, Withdrawn, Somatic Complaints; the Externalizing scales include the syndromes of Attention Problems and Aggressive Behavior; finally, the Neither Internalizing Nor Externalizing scales identify the syndromes of Sleep Problems and Other Problems that are not exclusively associated with other symptoms of the same internalizing or externalizing scales. The parent evaluates the child on every item with points from 0 to 3 according to the intensity and frequency which best describes the behavior of the child. High scores in the CBCL/1-5 subscales indicate child problems relate to Internalizing and/or Externalizing syndromes. Internal consistency coefficients for the CBCL/1-5 were quite satisfactory (alpha ranging from 0.65 to 0.96); criterion-related validity is supported by the ability of the CBCL’s quantitative scale scores to discriminate between demographically matched referred and non-referred children.

	RESULTS

TOP ABSTRACT INTRODUCTION MATERIALS AND METHODS RESULTS CONCLUSIONS REFERENCES

 
The first aim of our study was identifying dysfunctional relational modes during meals, comparing a group of mother and children in the first three years of life with normal development (ND-group) and a clinical group of dyads, in which children presented a diagnosis of feeding disorder and failure to thrive (FD-group). Furthermore, we investigated the age effect and its interaction with group.

A multivariate analysis of variance (MANOVA) was carried out on the four relational components of the Feeding Scale —Affective State of the Mother, Interactional Conflict, Food Refusal Behaviors of the Child, Affective State of the Dyad — with Group (ND-group vs. FD-group) and Age (7 levels) as independent variables.

The analysis showed significant differences between groups ( = 0.56; Rao (4, 316) = 62.35; p < 0.0001), age ( = 0.45; Rao (24, 1103) = 11.77; p < 0.0001) and their interaction ( = 0.79; Rao (24, 1103) = 3.15; p < 0.0001).

From univariate results on group effect, mother-child pairs in the FD-group showed higher scores than ND-group in Affective State of the Mother (respectively 13.31 vs. 9.70 as an average), in Interactional Conflict (respectively 17.12 vs. 10.18 as an average), in Food Refusal Behaviors of the Child (respectively 12.29 vs. 9.95 as an average), and in Affective State of the Dyad (respectively 4.17 vs. 2.84 as an average) (Fig. 1).

View larger version (26K): [in this window] [in a new window]   Fig. 1. Differences between groups for the four relational components of the Feeding Scale. ND-group = normal development group, FD-group = feeding disorder group.

Furthermore, interaction between Age and Group is significant for the relational component Interactional Conflict (F (6, 319) = 4.13; p < 0.001). As Fig. 2 shows, children without feeding disorders (ND-group) present scores that are substantially low and stable over time (in all of the age groups), while the scores for children with feeding disorders (FD-group) are significantly higher than the ND-group scores and show a peak in the 9–12 months age group, with a significant increase in conflict within the dyad, that then significantly diminishes starting from the second year of life (groups 12–18, 18–24 and 24–36 months).

View larger version (9K): [in this window] [in a new window]   Fig. 2. Interaction between Age and Group for the relational component Interactional Conflict (cross-sectional data). Ndgroup = normal development group, Fdgroup = feeding disorder group.

View larger version (13K): [in this window] [in a new window]   Fig. 3. Interaction between Age and Group for the relational component Food Refusal Behaviors of the Child (cross-sectional data). Ndgroup = normal development group, Fdgroup = feeding disorder group.

View larger version (11K): [in this window] [in a new window]   Fig. 4. Interaction between Age and Group for the relational component Affective State of the Dyad (cross-sectional data). Ndgroup-normal development group, Fdgroup = feeding disorder group.

As a first step, an analysis of the variance of the results obtained from the mothers of the clinical and control groups in the Eating Attitude Test (EAT-40 total score) was carried out. This showed a significant effect of the group (F (1, 98) = 5.26; p < 0.05), where mothers of children with feeding disorders have much higher total points (mean = 13.72, S.D. = 10.96) than the mothers of children without a feeding disorder (mean = 9.38, S.D. = 7.67).

The MANOVA analysis carried out on the scores obtained from mothers in the clinical and control groups on the three Global Indices of Distress from Symptom Checklist-90-Revised (SCL-90-R) (Global Severity Index, Positive Symptom Distress Index and Positive Symptom Total) showed a significant group effect ( = 0.89; Rao (3, 96) = 3.99; p < 0.05). Univariate analyses showed a significant group effect for Global Severity Index (F (1,98) = 9.91; p < 0.01) and Positive Symptom Total (F (1,98) = 8.18; p < 0.01), mothers of children in the FD-group presenting higher scores in both indices. A MANOVA conducted on three SCL-90-R subscales (anxiety, depression and hostility), pointed up a significant group effect ( = 0.85; Rao (3, 96) = 5.43; p < 0.01). In particular, univariate analyses demonstrated a significant group effect for Depression (F (1, 98) = 16.55; p < 0.001), Anxiety (F (1, 98) = 6.41; p < 0.05) and Hostility (F (1, 98) = 6.2; p < 0.05). Fig. 5 indicates scores obtained from mothers in the two groups for the latter dimensions of the SCL-90-R.

View larger version (24K): [in this window] [in a new window]   Fig. 5. Scores obtained for mothers in the two groups for the three dimensions Depression, Anxiety and Hostility of the Symptom Checklist-90-R. ND-group = normal development group, FD-group = feeding disorder group.

A MANOVA analysis conducted on the three relevant subscales of the CBCL (anxiety/depression, somatic complaints and aggressive behavior) showed a significant group effect ( = 0.70; Rao (3, 62) = 9.17; p < 0.001). Univariate analyses pointed out that children from FD-group had significantly higher scores in anxiety/depression (F (1, 64) = 9.54; p < 0.01), somatic complaints (F (1, 64) = 22.80; p < 0.001) and aggressive behavior (F (1, 64) = 4.54; p < 0.05). Fig. 6 reports scores obtained from the two groups in these three dimensions of the CBCL.

View larger version (28K): [in this window] [in a new window]   Fig. 6. Scores obtained for the children of the two groups for the three dimensions (Anxiety/Depression, Somatic Complaints and Aggressive Behavior) of the Child Behavior Checklist. ND-group = normal development group, FD-group = feeding disorder group.

As can be seen in Table 2, a high correlation, despite not being significant, emerged in the youngest children (1–10 months) between difficult management of the child and symptoms of depression in the mother; a high correlation was also seen between irregularity of the child’s biological rhythms (10–18 months) and all of the symptomatic characteristics of the mother considered. Furthermore, a significant association between most of the maternal symptomatic characteristics and problems in emotional/adaptive functioning of older children (18–36 months), represented by anxious/depressive and somatic symptoms and aggressive behavior was seen.

	DISCUSSION

 
The primary objective of our research was to identify, through the use of an innovative procedure of observation, dysfunctional relational modes in a sample of dyads in which the child presented a feeding disorder and non-organic failure to thrive syndrome.

The results obtained showed interactional dysfunctional patterns in the dyads of the Feeding Disorder group (FD-group); these mother-child pairs, in fact, reported higher scores than the control group pairs in the four relational areas of the Feeding Scale.

In particular, in the mother-child dyads of the FD-group, we found difficulties in expressing positive affect on the part of the caregiver. These caregivers showed more negative affect, such as sadness, emotional detachment and distress, as well as lower ability to read the communication signals of the child and tune into them (higher score in Affective State of the Mother). These dyads showed more conflict in communication exchanges and were non-collaborative and non-empathetic (higher scores in Interactional Conflict). Furthermore, the children revealed problematic characteristics of the feeding patterns, indicating food refusal, poor nutritional intake and difficult regulation of state during meals and aspects of temperamental difficulties, such as hyper/hypo-reactivity of babies and behavioral problems such as opposition, negativity, stubbornness of older children (higher scores in Food Refusal Behaviors of the Child). Finally, these dyads present higher scores in the Affective State of the Dyad, showing more difficulties, on the mother’s part, in facilitating the child’s autonomous initiatives and self-regulatory abilities, due to intrusive and constant control during meals; in the feeding exchange, behaviors of distress, on the child’s part, are intensely reactive and contrary, and the two partners show negative involvement in the relation, with the expression of anger and hostility.

Taking into consideration the effect of age on mother-child relational modes during feeding, our work is in agreement with other studies present in the literature. It can clearly be evidenced that, in the first three years of life, interactive exchanges and affective experiences between child and caregiver during feeding are organized into patterns of development, which gradually express the growing need for autonomy and emotional-affective separation of the child [2,41]. The results of our research show that, in both groups (Normal Development group and Feeding Disorder group) food refusal behaviors increased in the older groups of children. The child becomes, in fact, progressively more active and expresses the natural drive towards increasing his/her autonomy, through behavior which is contrary, as when, for example, the child refuses and/or spits out food or refuses to be fed by the mother. The mother-child pair must therefore negotiate "control" over the feeding situation, where the emotional availability of the caregiver is extremely important in supporting the child’s natural drive for autonomy.

In any case, in ND- and FD-groups food refusal behavior tends to decrease in the third year of life, but the scores of the children with feeding disorders are higher for all age levels and significantly different from the ND-group, with the exception of the 1 to 9 month old children. Furthermore, in the mother-child pairs with feeding disorders, the affective state of the dyad is more greatly characterized by negative emotions, i.e. crying, negativity and opposition of the child, lack of reciprocity in communicative exchanges and distress within the dyad. The increase in conflict in these pairs, together with the persistence of food refusal behavior by the child and negative affect of anger and hostility, show a highly problematic relation between the mother and children with feeding disorders in the first three years of the child’s life.

The analyses carried out to test the second objective of our research showed an association between specific symptomatic characteristics of mothers (dysfunctional eating attitudes, depression, anxiety, hostility), specific symptomatic characteristics of older children (anxiety/depression, somatic complaints, aggressive behavior) and dysfunctional relational modes during feeding and suggested an association between symptomatic characteristics of babies (particularly difficult manageability and irregularity of biological rhythms) and dysfunctional relational modes during feeding.

Our results are in line with other studies reported in the literature and show that a dysfunctional attitude to food and feeding, anxiety, depression and intrusiveness on the mother’s part constitute symptomatic characteristics that may be associated with feeding disorders and the syndrome of non-organic failure to thrive in infancy and early childhood [1,2,33,34].

Empirical evidence in our research of temperamental difficulties and emotional/behavioral problems in children with feeding disorders and non-organic failure to thrive syndrome is in agreement with other studies [2,3,32]. More particularly, high correlations between the group of babies with an early disorder of feeding regulation and a difficult manageability and irregularity of the basic rhythms emerged, measured from the high scores in specific areas of the BBQ-TBQ Questionnaires (Manageability, Regularity). Moreover, in older children, after the first year of life, feeding disorders were significantly associated with emotional/behavioral problems, such as feeding regulation complaints, anxiety during separation from the caregiver, moodiness, contrary and uncooperative behavior, stubbornness and angry moods, seen in the high scores in the specific scales Internalizing and Externalizing of the CBCL/1-5 (Somatic complaints, Anxiety/depression, Aggressive behavior).

Furthermore, the results of our research showed a significant association between the symptomatic status of the mother and of the child and the problematic nature of their relation during meals, measured from the dysfunctional modalities of interactive exchanges in the Feeding Scale.

We suggest that, already in the first year of life, difficult manageability of the child, characterized mainly by irritability, negative emotionality and irregularity in the basic rhythms (feeding and sleeping) can interact with the "vulnerability" of the mother, who presents anxious and depressive symptoms or negative eating attitudes which interfere with empathic recognition of the signs of hunger and fullness in the child. Furthermore, evidence of a significant association between maternal symptomatic characteristics (dysfunctional eating attitudes, depression, anxiety, hostility) and symptomatic characteristics of a somatic type, anxiety-depression and aggression in older children in our clinical group, shows that, with increasing age of the child, an inadequate internal regulation of feeding rhythms may persist and present an anxious, conflicted and intensely problematic involvement in the relation with the mother.

If we consider the correlations that emerged between the symptomatic characteristics of the mother and the child and the relational dimensions represented in the Feeding Scale in more detail, it can be seen that maternal symptomatological status is more strongly associated with dysfunctional patterns of the relation, with respect to the symptomatic characteristics of children (Tables 3). Thus, we suggest that a feeling of inadequacy when offering food to the child and symptoms of anxiety and depression of mothers greatly influence the dysfunctional feeding exchanges that characterize the relation between the caregiver and the child with a feeding disorder and non-organic failure to thrive (Table 3). In any case, difficult temperament and emotional/behavioral problems in the children seem to be associated with negative affect of the mothers and conflicted interactions during feeding (Table 3). This latter finding suggests that the influences of symptomatic characteristics of children and maternal vulnerabilities (as rated by caregivers) on dysfunctional feeding interactions may be additive.

Finally, the results of our analyses underline the effects of psychological and relational aspects in the clinical evaluation of child feeding disorders and non-organic failure to thrive syndrome. In particular, our research has identified an empirical association, in infantile feeding disorders, between specific symptomatic characteristics of the mother (dysfunctional eating attitudes, anxiety, depressive affects and hostility), of the child (poor feeding regulation, temperamental difficultness, anxiety at separation from the caregiver, uncooperative behavior, moodiness, angry moods) and a conflict-filled child-caregiver relation in the context of feeding. Feeding is characterized by intense distress within the dyad, intrusiveness and control, lack of synchronization, breakdown of interaction and emotional distance.

	CONCLUSIONS

TOP ABSTRACT INTRODUCTION MATERIALS AND METHODS RESULTS CONCLUSIONS REFERENCES

 
Our research highlights the importance of a global and integrated model in the clinical-diagnostic assessment of early feeding disorders that takes in to account possible associations between organic, psychological and relational factors for the formulation of a diagnosis and of strategies for targeted and effective intervention.

The results of our study threw light on the interconnections and reciprocal influences between the processes of development of feeding abilities during the first three years of life, temperamental characteristics and the emotional/adaptive functioning of the child, together with the symptomatic characteristics of mothers and the affective/relational experiences of the dyad. This multi-factorial and transactional approach shows that a feeding disorder and non-organic failure to thrive syndrome may be the result of competing factors including specific symptomatic characteristics of the mother (dysfunctional eating attitudes, anxiety, depression, hostility) and of the child (difficult manageability, irregularity of the biological rhythms, moodiness, stubbornness, angry moods) which have been found to be associated with negative and difficult mother-child interactions during feeding.

Therefore, our research confirms that analysis of the individual characteristics of the child, of the mother and of their relationship during the development of feeding patterns in the first three years of the child’s life, is extremely important in the evaluation of early feeding disorders, in order to establish a valid diagnostic methodology that is reliable and can be shared with other clinicians and researchers. Furthermore, the results that emerged emphasize the clinical utility of our study in regards to early identification of infants and toddlers at risk for feeding problems.

However, it is necessary to underline some limitations of our research, which represents a first attempt to explore association between specific symptomatic characteristics of the mother and perceptions of emotional/adaptive functioning of the child. The cross-sectional design of this study limits our ability to make strong claims regarding the origins of feeding disorders and non-organic failure to thrive syndrome. In addition, clinical evaluation of children emotional/behavioral problems and of the maternal psychopathological status are needed to clarify whether maternal self-report ratings on their own as well as on their children reflect objective characteristics or maternal perceptions.

Taking into consideration these limitations, the future course of our work will be directed towards confirming the validity of our results by examining larger samples for clinical and observational evaluation with regard to specific symptomatic characteristics of the mother and the child. Furthermore, we intend to carry out further study into psychological risk, with the analysis of other factors that may be associated with the symptomatic characteristics of mothers and children with feeding disorders and non-organic failure to thrive syndrome and to the dysfunctional modalities of their relation, i.e., insecure models of mother-child attachment, family stressors, conflicting and unstable marital relationships. Finally, our research may be able to take advantage in future of new data derived from a longitudinal study of our sample of children with early feeding disorders and of their mothers and which will be evaluated in follow-up.

Received January 20, 2003. Accepted September 10, 2003.

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TOP ABSTRACT INTRODUCTION MATERIALS AND METHODS RESULTS CONCLUSIONS REFERENCES

 

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