Mothers with an eating disorder: ‘food comes before anything’

There is little research that has presented the voices of mothers with an eating disorder (ED). The aim of this study was to clinicians present the experiences of mothers, drawn from the community, who have an ED and their perceptions regarding how their ED impacts on their children and parenting. Semi-structured, individual interviews were conducted with nine mothers with various EDs. Interpretative Phenomenological Analysis, alongside member checks and inter-rater reliability, was employed to analyze data. Six themes were identified: (1) the impact of an ED on children; (2) modelling disturbed eating behaviours; (3) prioritizing food before children’s needs, or as described by one participant, ‘food comes before anything’; (4) children motivate recovery; (5) secrecy within families; and (6) treatment needs. Overall, mothers juggled to balance the competing demands of an ED and the needs of their children. The need for clinicians to acknowledge and support a mother’s role when treating EDs is highlighted. Eating disorders (EDs) can have serious adverse complications on the individual but also on that individual’s family, including his or her children. While there are several qualitative studies exploring the experiences of parents with a mental illness, these typically do not differentiate between disorders. Most research on parents with an ED measures the consequences of a mothers’ ED in terms of an infant’s birth weight, the impact of the ED on children’s development or the logistics of feeding time regimes. There is little research that has captured the subjective experiences of mothers with an ED. This paper explores the issues for mothers with an ED and their perceptions regarding the impact of their ED on children. Marked by symptoms from one of three EDs, anorexia nervosa (AN), bulimia nervosa (BN) and EDs not otherwise specified (EDNOS), an individual with an ED experiences severely disturbed eating behaviour with significant physical, emotional and lifestyle effects including but not limited to episodic binge eating, abstinence from food, purging after eating or a general preoccupation with weight, shape and dieting (American Psychiatric Association 2000). Audit records of an adult outpatient ED service in the UK found that approximately one third of female clients were mothers, or mothers to be (Bryant-Waugh et al. 2007), indicating that a substantial number of those presenting for treatment with an ED have, or will have, children. Journal of Psychiatric and Mental Health Nursing, 2014, 21, 509–517 © 2013 John Wiley & Sons Ltd 509 Across diagnostic groups, a strong connection has been established between parental mental illness and increased lifetime psychiatric risk for their children due to various genetic, parenting, family and community factors (for a review see Reupert & Maybery 2007). For example, Hosman et al. (2009) reviewed various longitudinal studies and found that the risk of developing mental disorders among children whose parents have various mental disorders ranges from 41% to 77%. Much of the qualitative work in this field has explored the perspective of mothers with disorders such as bipolar disorder, depression or schizophrenia, usually without differentiating the parent’s diagnosis. Nonetheless, some common themes can be identified across parental disorders, especially around the sense of purpose parenting brings to those with a mental illness (Montgomery et al. 2006; Dolman et al. 2013). Other issues include the stigma and subsequent isolation for many families where a parent has a mental illness (Diaz-Caneja & Johnson 2004) and the reluctance of mothers to seek help in their parenting role, primarily due to fears around the involvement of child protection authorities (Dolman et al. 2013). Some mothers prioritize their children’s needs over their own self-care needs, for example, by not taking medication in order to be responsive to children (Montgomery et al. 2006). Enmeshment issues have been identified, with mothers describing overly close relationships with their children, and a tendency to be lax because they felt sorry for their children having to ‘put up’ with their mental illness (Ackerson 2003). The specific and potentially different experiences of parents with an ED have been overlooked in such research. Past research on parenting with an ED has predominately been of a quantitative nature that fails to capture the subjective experiences of families where a parent has an ED. For example, infants of women with AN and/or BN had significantly lower birth weights than control infants (Waugh & Bulik 1999) though another study found that infants of women with a history of BN were overweight at nine months (Micali et al. 2007). Mothers with EDs fed their children on a less regular schedule and tended to use food for non-nutritive purposes (as a reward or to calm a child) (Agras et al. 1999). Compared to mothers free of psychopathology, those with an ED were found to be more intrusive with their infants during mealtimes (Stein et al. 1994) and made significantly fewer positive comments about food and eating (Stein et al. 2006). Stein et al. (2006) found that children whose mothers had an ED adopted disturbed eating habits and were at a higher risk for developing ED psychopathology, than offspring with mothers with no ED. Other quantitative research has focused on how having an ED can impact on a mothers’ sense of well-being and the parent–child bond. Using self-report questionnaires, Koubaa et al. (2008) found that up to 92% of women with EDs reported clinically significant maternal adjustment problems and did not enjoy feeding their child. Another study found that a weak maternal-foetal attachment during pregnancy resulted in exacerbating ED symptoms for Chinese pregnant women with a history of bulimia (Pui-yee Lai et al. 2006). How mothers make sense of the ED within the context of family life is not explored in these studies. Two studies have been located that explore the subjective experiences of mothers with an ED. Bryant-Waugh et al. (2007) interviewed seven mothers, recruited from a specifically designed support programme in the UK for mothers with an ED and who all had children under five. Participants highlighted a fear of passing on problematic eating patterns to their children, difficulties in preparing food and a lack of knowledge in how to regulate nutritional intake during pregnancy. In Norway, interview data drawn from eight mothers recruited from psychiatric units, identified an overarching theme around being guilty as a mother in the context of eating difficulties and two subthemes in relation to being a good enough mother and a concern about their children being involved in the ED (Rørtveit et al. 2009). However, both studies drew on participants from treatment facilities. The present study also interviews parents with an ED but this time from the community rather than from clinics – this allows for claims to be made about the validity of the conclusions drawn from the two previous qualitative studies, which might then be applicable in more than one context, especially outside of treatment settings. Service decisions will be better informed and more likely to be utilized if clients’ views are heard and had their views genuinely considered. Hence, the current study aimed to identify parents’ perceptions regarding the impact of the ED on their children and parenting.