Journal of Pediatric Psychology. Vol. 16, No. 5. 1991. pp. 629-642
Lynda A. Archer,2 Peter L. Rosenbaum and David L. Streiner McMaster University Received June 5. 1990; accepted November 7. 1990
Eating and mealtime problems are common in childhood. They occur across a broad age span, in normally developing children and in a wide variety of developmental and medical disorders. There is no currently available standard instrument by which to assess these problems. The Children's Eating Behavior Inventory (CEBI) was developed according to a conceptual framework based upon a transactionallsystemic understanding of parent-child relationships. It was completed by 206 mothers of nonclinic children and 110 mothers of clinic children. Results of test-retest and internal reliability testing indicate that the CEBI meets criteria for instrument reliability. Construct validity is demonstrated by the significant difference between the clinic and nonclinic groups in the mean total eating problem score and in the mean number of items perceived to be a problem. KEY WORDS: eating behavior, children; assessment.
'The research described herein is supported by a grant from the Hospital for Sick Children Foundation (#XG 89-004) awarded to Lynda A. Archer. Appreciation is expressed to many individuals including several family physicians in the Hamilton-Wentworth area, members of the Departments of Pediatrics and Psychiatry at Chedoke-McMaster Hospitals, Oded Bar-Or and Mike Brown of the Children's Exercise and Nutrition Clinic, many staff from the Children's Developmental Rehabilitation Centre, clinical nutritionist Diane Pirhonen, the Infant-Parent Program at Mississauga Hospital, and the Phenylketonuria Clinic at the Hospital for Sick Children, Toronto. Special thanks to Charles E. Cunningham for his conceptual assistance in the early stages of the project and to Lisa Buckingham for her excellent data management and statistical analyses. 2 A11 correspondence should be addressed to Lynda A. Archer, Department of Psychology, Chedoke Child and Family Centre, Evel 1, Chedoke-McMaster Hospitals, Hamilton, Ontario L8N 3Z5, Canada. 629 0146-8693/9I/I00O-O629S06.50/0 © 1991 Plenum Publishing Corporation
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The assessment and treatment of E/M problems has been highly variable reflecting the involvement of a wide variety of disciplines and the absence of an overall conceptual framework and classification system from which to view these problems (Dahl & Sundelin, 1986). A major issue in the area has been the absence of a standardized assessment instrument. Case reports and anecdotal comments indicate that the day-to-day management of childhood E/M problems can be highly stressful to parent-child interactions and to family functions overall (Archer, Cunningham, & Whelan, 1988; Archer & Szatmari, 1990; Chatoor, Conley, & Dickson, 1988; Hagekull & Dahl, 1987). An instrument that could screen for E/M problems, provide an objective assessment of the type and severity of the problem, and provide a measure of the degree of stress to the caretaker would represent a significant advance in the field. The Children's Eating Behavior Inventory (CEBI), a parent-report instrument, is conceptually derived from a transactional/systemic approach to childhood eating and mealtime problems (further discussion of such an approach to these problems is given in Archer, 1990). The CEBI is intended to assess E/M problems across a broad age span and in a wide variety of medical and developmental disorders. We endorse Linscheid's (1983) proposal that childhood E/M disorders be regarded as a separate clinical entity regardless of medical diagnosis.
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Eating and mealtime (E/M) problems in childhood are common in both clinic and nonclinic populations. Palmer, Thompson, and Linscheid (1975) estimated that 25 to 35% of children referred to an outpatient pediatric clinic had recognized or reportable eating problems. Similar figures have also been suggested for nonclinic populations (Hertzler, 1983). Linscheid (1983) suggested that the prevalence may be significantly higher in clinic groups both because parents fail to report eating problems when another more pervasive disorder is present and because clinicians fail to identify them. Because E/M problems are "functional" rather than "medical" they are often not perceived as falling in the medical realm. These functional eating problems are often the consequence of therapeutic decisions such as the need for increased frequency of feeding or special dietary management. They may derive from parental worry or fear of inadequate nutritional intake in an ill child, and thereby result in an undue focus on the volume and/or mechanical aspects of feeding. Whatever their origins, such problems commonly accompany childhood illnesses, and may be considered generic difficulties because they are not specifically and primarily medical. They may be missed by health professionals addressing the major diagnostic disorder while neglecting these vital components of the daily interaction of child and caregiver.
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METHOD Questionnaire Construction
Item Scaling and Scoring. For each item, the respondent indicates on a 5point Likert response scale how often the behavior occurs (i.e., never, seldom, sometimes, often, always). Twenty-eight items are scored positively, 12 items are scored in the negative direction. The respondent also records whether she perceives an item to be a problem by answering Yes or No to the question "Is this a problem for you?" Two scores are derived from the instrument. The total eating problem score is obtained by adding the scores for each item (the highest possible score is 5 for each item). The total number of items perceived to be a problem is determined by adding the number of "Yes" responses to the question "Is this a problem for you?" Subjects All cases were recruited by consecutive case procedures. The 110 clinic (CL) subjects came from outpatient pediatric and mental health clinics. The 206 subjects in the nonclinic group (NCL) were normally developing children re-
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Item Selection and Content. Items for the CEBI were generated by colleagues familiar with children with E/M problems and from descriptions in the literature of children's E/M problems. In addition, inclusion of items in the CEBI was guided conceptually by the intent of the instrument to (a) reflect the contribution of child, parent, and family factors to E/M problems, (b) be applicable across a broad age span, and (c) be useful in a variety of developmental and medical conditions (Streiner & Norman, 1990). The CEBI has 40 items (see Appendix). Phi-coefficient analyses of data from the first version resulted in a reduction of the item pool from 71 to 40 items (Archer & Cunningham, 1988). The items can be grouped into two broad categories: items pertaining to the child, and items pertaining to the parent and family system. The 28 items in the child domain are intended to assess food preferences, motor skills, and behavioral compliance. The 12 items in the parent domain are intended to assess parental child behavior controls, cognitions and feelings about feeding one's child, and interactions between family members. Two skip patterns were developed to permit the inclusion of single-parent families and families with only one child. Single parents skip four items leaving a total of 36 items. Two-parent families with only one child skip one item leaving a total of 39 items. In these cases a weighting system was devised to compensate for the omitted items.
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cruited from 11 community family physicians' offices in the Hamilton-Wentworth Region. This was deemed the most parsimonious manner of recruiting a large number of children across a broad age span, including both preschool age and school age children. To provide for educational and socioeconomic diversity in the nonclinic subjects an effort was made to approach physicians practicing in different parts of the region. However, this was not done in any systematic manner. Inclusion criteria for the clinic cases were (a) children 2.0 to 12.11 years of age, (b) children referred for assessment and treatment of an identified eating problem, and (c) children with developmental or medical disorders likely to place them at risk for E/M problems as determined from clinical experience and reports in the literature. The six children in the identified eating problem group had a variety of diagnosesincluding nonorganic failure to thrive (n = 1), specific language disorder (n = 1), food refusal (n= 1), and mental retardation (n = 3). All had been referred for assessment and treatment of E/M problems. Subjects in the "at risk" clinic group included obese (n = 30), autistic (n = 9), physically disabled (n = 46), mentally handicapped (n = 11), phenylketonuric (n — 7), and Prader-Willi (n = 1) children. To be considered obese, subjects were above 30% body fat as determined by body underwater weighing (Lohman, 1986). Subjects with obesity in the presence of another medical or developmental disorder (e.g., cerebral palsy, cystic fibrosis) were excluded. Children in the autistic group came from an ongoing study of autistic children. With the exception of 6 cases who were autistic but had IQs below 68, all were higher functioning autistics (IQ above 68) who met DSM-III-R criteria for Pervasive Developmental Disorder (American Psychiatric Association, 1987). Children in the physically disabled group had been referred to a local children's rehabilitation center and included primarily children with cerebral palsy and spina bifida. Children in the mentally handicapped group were recruited from centers or programs for the developmentally handicapped. Twenty-four cases (7%) were excluded from the data analyses due to spoiled questionnaires. Of these, 13 came from the clinic group and 11 from the nonclinic group. Because subjects were obtained from several different clinics and programs simultaneously, this precluded having a research assistant on site for questionnaire administration. Therefore, it was not possible to systematically monitor the number of times the CEBI was refused. However, anecdotal reports from both clinic and nonclinic sources indicated that the CEBI was well received and that there were almost no refusals. In the small number of instances when it was refused this seemed to be related less to the CEBI than to the fact that the mother had already been approached to participate in several other projects. Demographic information for both groups is given in Table I. Analyses of variance and / tests showed that the groups did not differ on any of a large number of demographic variables including sex and age of the child, parental age, marital status and education, family size, mother's history of eating prob-
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Table I. Demographic Information for CLinic and Nonclinic Groups Nonclinic (n == 206) Variable
%
104 51 102 49 (5.9 :t 3.10)
n
%
61 55 49 45 (7.1 ± 3.32)
36 41
18 20
18 17
16 16
63
31
33
30
42 64 58 38
20.8 31.7 28.7 18.8
18 42 34 12
17.0 39.6 32.1 11.3
35 52 39 42
20.8 31.0 23.2 25.0
22
25.3 27.6 26.4 20.7
24 23 18
lems as a child. Maternal history of an eating problem was determined by the mother's yes/no response to the question, "Have you yourself ever had any eating/mealtime problems." Procedure The CEBI, including the demographic questions and a cover letter explaining the project, took approximately 15 minutes to complete. A detailed instruction sheet telling the respondent how to complete the questionnaire was also used. All questionnaires were completed by mothers. The instructions for mothers of the nonclinic subjects included an additional instruction that they fill out the CEBI for their youngest (or oldest) child between 2 and 12 years, if they had more than one child. In other words, 50% of the CEBIs said youngest child; 50% said oldest child. This procedure was taken to prevent the parent from choosing to complete the form either for a child who did have some eating problems or for a child who ate particularly well. The questionnaires were completed as part of a routine clinic visit. Both clinic and nonclinic subjects were approached by their physician or clinic therapist after instructions from the research personnel about how to present the questionnaire. To control for selection bias, clinicians were instructed to offer the CEBI to all mothers, even those whom they thought might refuse to do it.
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Child Male Female Mean age (years ± SD) Family Single parent Only child Maternal self-report of eating problems Mother's education Some secondary or less Secondary College University Father's education Some secondary or less Secondary College University
n
Clinic (n = 110)
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RESULTS Test-Retest Reliability Test-retest reliability was determined for 38 cases (28 clinic and 10 nonclinic) 4 to 6 weeks (mean 33 days) after the initial completion. The intraclass correlation coefficient was .87 for the total eating problem score, and .84 for the percentage of items perceived to be a problem. Internal Consistency The coefficient alpha's for the different subgroups are shown in Table II. All of these are within acceptable limits (i.e., above .70) with the exception of the single parent/more than one child group which is markedly lower at .58.
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A retest was done for both clinic and nonclinic subjects 4 to 6 weeks after the first administration. Cases were chosen by consecutive case procedures. Some cases were not eligible to participate because the form was returned outside the 4- to 6-week time span. After obtaining telephone consent a second CEBI was mailed. Subjects were telephoned approximately 1 week after the mailing. Test-retest reliability was determined both for the total eating problem score and for the number of items perceived to be a problem. All mothers approached about the retesting agreed to participate and the return rate was 100%. To assess internal consistency of the CEBI, Cronbach alphas were computed. Because of missing data resulting from the skip pattern provided for single parents and families with one child, separate alpha coefficients were determined for (a) two parent/two children cases, (b) two parent/only child cases, (c) single parent/only child cases, and (d) single parent/two children cases. An alpha level of .05 was considered significant for all data analyses. Construct validity of the CEBI was derived from comparisons of the CEBI scores for the clinic group versus the nonclinic group. It was hypothesized that the total eating problem score would be higher for the clinic group and that the number of items perceived to be a problem would be greater for the clinic group. It was also predicted that, by virtue of their earlier developmental level in terms of motor and social/behavioral skills, the scores would be higher for younger children (2 to 6 years old) as compared with older children (7 to 12 years old). Because there are no other comparable existing instruments it was not possible to assess concurrent validity of the instrument at this time. To assess the distribution of children with E/M problems across the different groups, the data for each group were put into box plot graphs. Box plots provide a graphic presentation of data in which a variety of indices of central tendency and dispersion can be observed at one time for one or more groups. (The reader is referred to Tukey, 1977, for a more detailed discussion of box plots.)
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Table II. Internal Reliability Coefficients for Different Subgroups, Clinic and Nonclinic Subjects Combined Group
n
Cronbach's Alpha
Two parents/two or more children Two parents/one child Single parent/one child Single parent/two or more children
189 34 15 28
.76 .71 .76 .58
The total eating problem scores are significantly higher, F (1, 314) = 21.19,^ < .0001, for the clinic group (Table III). Mothers of clinic children also reported a significantly higher proportion, t (311) = 4.42, p < .0001, of the items to be a problem (Table III). The mean age for the clinic and nonclinic groups is different with the clinic group being approximately 1 year older, although this did not reach statistical significance. An analysis of covariance was done with age as the covariate. There was no difference in the total CEBI scores between the younger (2 to 6 years) and older (7 to 12 years) children either between groups or within groups (Table III). Based on the mean percentage of items perceived to be a problem (i.e., 20% for the clinic group and 13% for the nonclinic group), the midpoint between the two values (16%), was taken as the cutoff point for defining the presence of an eating problem. The number of cases for which 16% or more of the items were perceived to be a problem was significantly greater for the clinic group as compared with the nonclinic group (x 2 = 16.79, p < .0001). Fifty-six percent of mothers of clinic children reported 16% or more of the items to be a problem as Table III. Total Eating Problem Scores and Percentage of Items Perceived to be a Problem for Clinic and Nonclinic Croups by Age Group Nonclinic {n = 206)
Eating problem score Total sample0 2 to 6 years old 7 to 12 years old Percentage of items perceived to be a problem Total sample" 2 to 6 years old 7 to 12 years old °p < .0001.
Clinic (n = 110)
M
SD
M
SD
86.65 88.08 83.93
11.54 11.73 10.74
92.52 93.00 92.07
12.57 14.27 10.85
13.26 13.40 12.97
13.26 13.32 13.22
20.86 19.49 22.14
16.65 17.84 15.51
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Construct Validity
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r Aullsllc
> H
Eating Problem ———7—-—
60
70
80
90
100
110
120
130
Total Eating Problem Score Fig. 1. Box plots of total eating problem scores for clinic and nonciinic groups. Key parts of a box plot include (a) the asterisk in the middle which represents the median of the distribution, (b) the ends of the box which fall at the upper and lower quartiles such that the middle 50% of the cases fall within the box, (c) lines coming out the ends, "whiskers," which show the degree of dispersion in the data, and (d) the small circles beyond the whiskers are outliers. Sample size is represented in the thickness of the box; larger samples have thicker boxes.
compared with 33% of the mothers of children in the nonciinic group. None of the identified cases in the nonciinic group had been so identified by the family doctor. Box plots of the total eating problem scores for the clinic and nonciinic groups are given in Figure 1. The results show that children with eating problems occur in almost all the groups, but with the higher scores and greater numbers of cases occurring in the mentally handicapped, autistic, and eating problem groups. The PKU group has very little dispersion in its data and very few cases with eating problems. Conversely, there is considerable variability in the data from children with a physical disability.
DISCUSSION Reliability testing shows that the CEBI is a reliable instrument. Preliminary comparisons between clinic and nonciinic samples indicating higher scores for
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Physical Hanaicap
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the clinic group confirm the construct validity of the CEBI. As well, the CEBI specifies what the specific eating problems are and how stressful they are perceived to be by the mother. Because E/M problems can be highly disruptive and distressing to children and families, an instrument that can reliably assess these problems represents a significant advance in the field. The results confirm previous reports of the high prevalence of E/M problems in both nonclinic and clinic samples. In addition, the results show that E/M problems are l'/i times more common for children from clinic populations. The high rate of eating problems in children from the nonclinic sample who had not been referred for treatment suggest the potential application of the CEBI as a screening tool for children's eating/mealtime problems. A surprising finding is that age does not appear to be a relevant factor for the occurrence of E/M problems. The results from the box plot graphs show that E/M problems occurred in most groups tested. These findings provide initial support for the transactional/systemic conceptual orientation from which the CEBI is derived. In work in progress, the CEBI is being given in conjunction with measures of child behavior and family functioning. It is anticipated that these data will help to clarify further the role of parent-child-family interactional factors in relation to the medical condition and/or developmental disorder of the child in children's E/M problems. Clinical application of the CEBI with a small number of cases has confirmed the ability of the instrument to reflect improvement in E/M problems after an intervention (Archer & Szatmari, 1990; Archer et al., 1988). The CEBI may also serve as a companion questionnaire to be given with the Children's Eating Attitudes Test (ChEAT; Maloney, McGuire, & Daniels, 1988). The ChEAT is completed by children 8 to 13 years of age and provides a measure of the child's eating attitudes. Several of the items on the ChEAT are similar or identical to those on the CEBI. A possible limitation in the present study is a selection bias in the recruitment of subjects for both the nonclinic and clinic groups. Because we did not have research personnel present in the community physicians' offices or at all the pediatric clinics, it is possible that the questionnaire was selectively offered to more compliant mothers (for both the nonclinic and clinic samples) and, in the case of the clinic group to mothers of less handicapped children. This could then serve to underestimate the prevalence of E/M problems as well as depress both scores that were derived from the CEBI. However, the fact that the rates are already so high may mean on the other hand that a response set is occurring. Perhaps E/M problems are being inflated by the presence of another more primary behavioral/developmental problem in the child and or marital/family problems. The reason for the very low internal reliability level (alpha = .58) for single parents with more than one child is not readily apparent. In future studies we intend to look at the pattern of responding (i.e., specific
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APPENDIX CEBI Child's Name
Age
/ Years
Sex M F Months
HOW OFTEN DOES THIS HAPPEN? NEVER 1
SELDOM 2
SOMETIMES 3
OFTEN 4
ALWAYS 5 Is this
a problem for you? 1. My child chews food as expected for his/her age 2. My child helps to set the table 3. My child watches TV at meals 4. I feed my child if he/she doesn't eat 5. My child takes more than half an hour to eat his/her meals
1
2
3
4
5
YES NO
1
2
3
4
5
YES NO
1
2
3
4
5
YES NO
1
2
3
4
5
YES NO
1
2
3
4
5
YES NO
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items endorsed) in a variety of clinical groups including juvenile diabetic, autistic, obese, phenylketonuric, Prader-Willi, and physically disabled. These data may help us clarify the contribution of dietary, behavioral, interactional, and physical factors to children's E/M problems. In work currently underway, we are obtaining direct observational data (e.g., videotape recordings) of family dinner times in conjunction with the CEBI for both clinic and nonclinic cases. The videotape data will serve as a measure of construct and concurrent validity for the CEBI as well as providing information about family interactional patterns in which a child does and does not have an eating problem.
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NEVER 1
SELDOM 2
SOMETIMES 3
OFTEN 4
ALWAYS 5 Is this a problem for you? YES NO
2 2
3 3
4 4
5 5
YES NO YES NO
2
3
4
5
YES NO
4
YES NO
4
YES NO
4
YES NO
4
YES NO
4
YES NO
YES NO
YES NO 4 4
YES NO YES NO
YES NO
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6. Relatives complain about my child's eating 7. My child enjoys eating 8. My child asks for food which he/she shouldn't have 9. My child feeds him/her self as expected for his/her age 10. My child gags at mealtimes 11. I feel confident my . child eats enough 12. I find our meals stressful 13. My child vomits at mealtime 14. My child takes food between meals without asking 15. My child comes to the table 1 or 2 minutes after I call 16. My child chokes at mealtimes 17. My child eats quickly 18. My child makes foods for him/her self when not allowed 19. 1 get upset when my child doesn't eat
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SOME- OFALTIMES TEN WAYS 3 4 5 Is this a problem for you?
1
2
3
4
5
YES NO
1
2
3
4
5
YES NO
1
2
3
4
5
YES NO
1
2
3
4
5
YES NO
1
2
3
4
5
YES NO
1
2
3
4
5
YES NO
1
2
3
4
5
YES NO
1
2
3
4
5
YES NO
1
2
3
4
5
YES NO
1
2
3
4
5
YES NO
IF YOU ARE A SINGLE PARENT SKIP TO NUMBER 34. 30. My child's behavior at meals upsets my spouse
1
2
3
4
5
YES NO
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20. At home my child eats food he/shouldn't have 21. My child eats foods that taste different 22. I let my child have snacks between meals if he/she doesn't eat at meals 23. My child uses cutlery as expected for his/her age 24. At friends' homes my child eats food he/she shouldn't eat 25 My child asks for food between meals 26 I get upset when I think about our meals 27 My child eats chunky foods 28 My child lets food sit in his/her mouth 29. At dinner I let my child choose the foods he/she wants from what is served
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NEV- SELER DOM 1 2
SOMETIMES 3
OFTEN 4
ALWAYS 5 Is this a problem for you? YES NO
1
2
3
4
5
YES NO
1
2
3
4
5
YES NO
1
2
3
4
5
YES NO
1
2
3
4
5
YES NO
1
2
3
4
5
YES NO
1
2
3
4
5
YES NO
1 1
2 2
3 3
4 4
5 5
YES NO YES NO
IF YOU HAVE ONLY ONE CHILD SKIP NUMBER 40. 40. My child's behavior at meals upsets our other children
1
2
3
4
5
YES NO
PLEASE CHECK TO SEE THAT YOU HAVE ANSWERED ALL THE ITEMS. HAVE YOU CIRCLED A YES OR NO FOR EACH ITEM? THANK YOU.
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31. I agree with my spouse about how much our child should eat 32. My child interrupts conversations with my spouse at meals 33. I get upset with my spouse at meals 34. My child eats when upset 35. My child says he/she is hungry 36. My child says she/he'll get fat if she/he eats too much 37. My child helps to clear the table 38. My child hides food 39. My child brings toys or books to the table
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REFERENCES
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American Psychiatric Association. (1987). Diagnostic and statistical manual of mental disorders (3rd ed., rev.). Archer, L. (1990). Childhood eating and mealtime problems: Towards a multidimensional perspective. Manuscript submitted, McMaster University. Archer, L., & Cunningham, C. E. (1988). A transactional/systemic model of childhood eating and mealtime problems: Development of an instrument [Abstract]. Developmental Medicine and Child Neurology, J0(Suppl. 57), 42. Archer, L., Cunningham, C. E., & Whelan, D. (1988). Coping with dietary therapy in phenylketonuria: a case report. Canadian Journal of Behavioural Science, 20, 461-466. Archer, L., & Szatmari, P. (1990). Assessment and treatment of food aversion in a four-year old boy: A multidimensional approach. Canadian Journal of Psychiatry, 35, 501-505. Chatoor, I., Conley, C , & Dickson, L. (1988). Food refusal after an incident of choking: A posttraumatic eating disorder. Journal of the American Academy of Child and Adolescent Psychiatry, 27. 535-540. Dahl, M., & Sundelin, C. (1986). Early feeding problems in an affluent society. I. Categories and clinical signs. Acta Paediatrica Scandinavica, 75, 370-379. Hagekull. B., & Dahl, M. (1987). Infants with and without feeding difficulties: Maternal experiences. International Journal of Eating Disorders, 6, 83-98. Hertzler, A. A. (1983). Children's food patterns—a review: 1. Food preferences and feeding problems. Journal of the American Dietetic Association. 83, 551-554. Linscheid, T. R. (1983). Ealing problems in children. In C. E. Walker & M. C. Roberts (Eds.), Handbook of clinical child psychology (pp. 616-639). New York: Wiley. Lohman, T. G. (1986). Applicability of body composition techniques and constants for children and youths. Exercise and Sport Science Review, 14. 325-357. Maloney, M. J., McGuire, J. B., & Daniels, S. R. (1988). Reliability testing of a children's version of the Eating Attitude Test. Journal of the American Academy of Child and Adolescent Psychiatry, 27, 541-543. Palmer, S., Thompson, R. J., & Linscheid, T. R. (1975). Applied behavior analysis in the treatment of childhood feeding problems. Developmental Medicine and Child Neurology, 17, 333-339. Streiner, D., & Norman, G. (1989). Health measurement scales: A practical guide to their development and use. London: Oxford Medical Publications. Tukey, J. W. (1977). Exploratory data analysis. Reading, MA: Addison-Wesley.
Lynda A. Archer,2 Peter L. Rosenbaum and David L. Streiner McMaster University Received June 5. 1990; accepted November 7. 1990
Eating and mealtime problems are common in childhood. They occur across a broad age span, in normally developing children and in a wide variety of developmental and medical disorders. There is no currently available standard instrument by which to assess these problems. The Children's Eating Behavior Inventory (CEBI) was developed according to a conceptual framework based upon a transactionallsystemic understanding of parent-child relationships. It was completed by 206 mothers of nonclinic children and 110 mothers of clinic children. Results of test-retest and internal reliability testing indicate that the CEBI meets criteria for instrument reliability. Construct validity is demonstrated by the significant difference between the clinic and nonclinic groups in the mean total eating problem score and in the mean number of items perceived to be a problem. KEY WORDS: eating behavior, children; assessment.
'The research described herein is supported by a grant from the Hospital for Sick Children Foundation (#XG 89-004) awarded to Lynda A. Archer. Appreciation is expressed to many individuals including several family physicians in the Hamilton-Wentworth area, members of the Departments of Pediatrics and Psychiatry at Chedoke-McMaster Hospitals, Oded Bar-Or and Mike Brown of the Children's Exercise and Nutrition Clinic, many staff from the Children's Developmental Rehabilitation Centre, clinical nutritionist Diane Pirhonen, the Infant-Parent Program at Mississauga Hospital, and the Phenylketonuria Clinic at the Hospital for Sick Children, Toronto. Special thanks to Charles E. Cunningham for his conceptual assistance in the early stages of the project and to Lisa Buckingham for her excellent data management and statistical analyses. 2 A11 correspondence should be addressed to Lynda A. Archer, Department of Psychology, Chedoke Child and Family Centre, Evel 1, Chedoke-McMaster Hospitals, Hamilton, Ontario L8N 3Z5, Canada. 629 0146-8693/9I/I00O-O629S06.50/0 © 1991 Plenum Publishing Corporation
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The assessment and treatment of E/M problems has been highly variable reflecting the involvement of a wide variety of disciplines and the absence of an overall conceptual framework and classification system from which to view these problems (Dahl & Sundelin, 1986). A major issue in the area has been the absence of a standardized assessment instrument. Case reports and anecdotal comments indicate that the day-to-day management of childhood E/M problems can be highly stressful to parent-child interactions and to family functions overall (Archer, Cunningham, & Whelan, 1988; Archer & Szatmari, 1990; Chatoor, Conley, & Dickson, 1988; Hagekull & Dahl, 1987). An instrument that could screen for E/M problems, provide an objective assessment of the type and severity of the problem, and provide a measure of the degree of stress to the caretaker would represent a significant advance in the field. The Children's Eating Behavior Inventory (CEBI), a parent-report instrument, is conceptually derived from a transactional/systemic approach to childhood eating and mealtime problems (further discussion of such an approach to these problems is given in Archer, 1990). The CEBI is intended to assess E/M problems across a broad age span and in a wide variety of medical and developmental disorders. We endorse Linscheid's (1983) proposal that childhood E/M disorders be regarded as a separate clinical entity regardless of medical diagnosis.
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Eating and mealtime (E/M) problems in childhood are common in both clinic and nonclinic populations. Palmer, Thompson, and Linscheid (1975) estimated that 25 to 35% of children referred to an outpatient pediatric clinic had recognized or reportable eating problems. Similar figures have also been suggested for nonclinic populations (Hertzler, 1983). Linscheid (1983) suggested that the prevalence may be significantly higher in clinic groups both because parents fail to report eating problems when another more pervasive disorder is present and because clinicians fail to identify them. Because E/M problems are "functional" rather than "medical" they are often not perceived as falling in the medical realm. These functional eating problems are often the consequence of therapeutic decisions such as the need for increased frequency of feeding or special dietary management. They may derive from parental worry or fear of inadequate nutritional intake in an ill child, and thereby result in an undue focus on the volume and/or mechanical aspects of feeding. Whatever their origins, such problems commonly accompany childhood illnesses, and may be considered generic difficulties because they are not specifically and primarily medical. They may be missed by health professionals addressing the major diagnostic disorder while neglecting these vital components of the daily interaction of child and caregiver.
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METHOD Questionnaire Construction
Item Scaling and Scoring. For each item, the respondent indicates on a 5point Likert response scale how often the behavior occurs (i.e., never, seldom, sometimes, often, always). Twenty-eight items are scored positively, 12 items are scored in the negative direction. The respondent also records whether she perceives an item to be a problem by answering Yes or No to the question "Is this a problem for you?" Two scores are derived from the instrument. The total eating problem score is obtained by adding the scores for each item (the highest possible score is 5 for each item). The total number of items perceived to be a problem is determined by adding the number of "Yes" responses to the question "Is this a problem for you?" Subjects All cases were recruited by consecutive case procedures. The 110 clinic (CL) subjects came from outpatient pediatric and mental health clinics. The 206 subjects in the nonclinic group (NCL) were normally developing children re-
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Item Selection and Content. Items for the CEBI were generated by colleagues familiar with children with E/M problems and from descriptions in the literature of children's E/M problems. In addition, inclusion of items in the CEBI was guided conceptually by the intent of the instrument to (a) reflect the contribution of child, parent, and family factors to E/M problems, (b) be applicable across a broad age span, and (c) be useful in a variety of developmental and medical conditions (Streiner & Norman, 1990). The CEBI has 40 items (see Appendix). Phi-coefficient analyses of data from the first version resulted in a reduction of the item pool from 71 to 40 items (Archer & Cunningham, 1988). The items can be grouped into two broad categories: items pertaining to the child, and items pertaining to the parent and family system. The 28 items in the child domain are intended to assess food preferences, motor skills, and behavioral compliance. The 12 items in the parent domain are intended to assess parental child behavior controls, cognitions and feelings about feeding one's child, and interactions between family members. Two skip patterns were developed to permit the inclusion of single-parent families and families with only one child. Single parents skip four items leaving a total of 36 items. Two-parent families with only one child skip one item leaving a total of 39 items. In these cases a weighting system was devised to compensate for the omitted items.
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cruited from 11 community family physicians' offices in the Hamilton-Wentworth Region. This was deemed the most parsimonious manner of recruiting a large number of children across a broad age span, including both preschool age and school age children. To provide for educational and socioeconomic diversity in the nonclinic subjects an effort was made to approach physicians practicing in different parts of the region. However, this was not done in any systematic manner. Inclusion criteria for the clinic cases were (a) children 2.0 to 12.11 years of age, (b) children referred for assessment and treatment of an identified eating problem, and (c) children with developmental or medical disorders likely to place them at risk for E/M problems as determined from clinical experience and reports in the literature. The six children in the identified eating problem group had a variety of diagnosesincluding nonorganic failure to thrive (n = 1), specific language disorder (n = 1), food refusal (n= 1), and mental retardation (n = 3). All had been referred for assessment and treatment of E/M problems. Subjects in the "at risk" clinic group included obese (n = 30), autistic (n = 9), physically disabled (n = 46), mentally handicapped (n = 11), phenylketonuric (n — 7), and Prader-Willi (n = 1) children. To be considered obese, subjects were above 30% body fat as determined by body underwater weighing (Lohman, 1986). Subjects with obesity in the presence of another medical or developmental disorder (e.g., cerebral palsy, cystic fibrosis) were excluded. Children in the autistic group came from an ongoing study of autistic children. With the exception of 6 cases who were autistic but had IQs below 68, all were higher functioning autistics (IQ above 68) who met DSM-III-R criteria for Pervasive Developmental Disorder (American Psychiatric Association, 1987). Children in the physically disabled group had been referred to a local children's rehabilitation center and included primarily children with cerebral palsy and spina bifida. Children in the mentally handicapped group were recruited from centers or programs for the developmentally handicapped. Twenty-four cases (7%) were excluded from the data analyses due to spoiled questionnaires. Of these, 13 came from the clinic group and 11 from the nonclinic group. Because subjects were obtained from several different clinics and programs simultaneously, this precluded having a research assistant on site for questionnaire administration. Therefore, it was not possible to systematically monitor the number of times the CEBI was refused. However, anecdotal reports from both clinic and nonclinic sources indicated that the CEBI was well received and that there were almost no refusals. In the small number of instances when it was refused this seemed to be related less to the CEBI than to the fact that the mother had already been approached to participate in several other projects. Demographic information for both groups is given in Table I. Analyses of variance and / tests showed that the groups did not differ on any of a large number of demographic variables including sex and age of the child, parental age, marital status and education, family size, mother's history of eating prob-
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Table I. Demographic Information for CLinic and Nonclinic Groups Nonclinic (n == 206) Variable
%
104 51 102 49 (5.9 :t 3.10)
n
%
61 55 49 45 (7.1 ± 3.32)
36 41
18 20
18 17
16 16
63
31
33
30
42 64 58 38
20.8 31.7 28.7 18.8
18 42 34 12
17.0 39.6 32.1 11.3
35 52 39 42
20.8 31.0 23.2 25.0
22
25.3 27.6 26.4 20.7
24 23 18
lems as a child. Maternal history of an eating problem was determined by the mother's yes/no response to the question, "Have you yourself ever had any eating/mealtime problems." Procedure The CEBI, including the demographic questions and a cover letter explaining the project, took approximately 15 minutes to complete. A detailed instruction sheet telling the respondent how to complete the questionnaire was also used. All questionnaires were completed by mothers. The instructions for mothers of the nonclinic subjects included an additional instruction that they fill out the CEBI for their youngest (or oldest) child between 2 and 12 years, if they had more than one child. In other words, 50% of the CEBIs said youngest child; 50% said oldest child. This procedure was taken to prevent the parent from choosing to complete the form either for a child who did have some eating problems or for a child who ate particularly well. The questionnaires were completed as part of a routine clinic visit. Both clinic and nonclinic subjects were approached by their physician or clinic therapist after instructions from the research personnel about how to present the questionnaire. To control for selection bias, clinicians were instructed to offer the CEBI to all mothers, even those whom they thought might refuse to do it.
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Child Male Female Mean age (years ± SD) Family Single parent Only child Maternal self-report of eating problems Mother's education Some secondary or less Secondary College University Father's education Some secondary or less Secondary College University
n
Clinic (n = 110)
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RESULTS Test-Retest Reliability Test-retest reliability was determined for 38 cases (28 clinic and 10 nonclinic) 4 to 6 weeks (mean 33 days) after the initial completion. The intraclass correlation coefficient was .87 for the total eating problem score, and .84 for the percentage of items perceived to be a problem. Internal Consistency The coefficient alpha's for the different subgroups are shown in Table II. All of these are within acceptable limits (i.e., above .70) with the exception of the single parent/more than one child group which is markedly lower at .58.
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A retest was done for both clinic and nonclinic subjects 4 to 6 weeks after the first administration. Cases were chosen by consecutive case procedures. Some cases were not eligible to participate because the form was returned outside the 4- to 6-week time span. After obtaining telephone consent a second CEBI was mailed. Subjects were telephoned approximately 1 week after the mailing. Test-retest reliability was determined both for the total eating problem score and for the number of items perceived to be a problem. All mothers approached about the retesting agreed to participate and the return rate was 100%. To assess internal consistency of the CEBI, Cronbach alphas were computed. Because of missing data resulting from the skip pattern provided for single parents and families with one child, separate alpha coefficients were determined for (a) two parent/two children cases, (b) two parent/only child cases, (c) single parent/only child cases, and (d) single parent/two children cases. An alpha level of .05 was considered significant for all data analyses. Construct validity of the CEBI was derived from comparisons of the CEBI scores for the clinic group versus the nonclinic group. It was hypothesized that the total eating problem score would be higher for the clinic group and that the number of items perceived to be a problem would be greater for the clinic group. It was also predicted that, by virtue of their earlier developmental level in terms of motor and social/behavioral skills, the scores would be higher for younger children (2 to 6 years old) as compared with older children (7 to 12 years old). Because there are no other comparable existing instruments it was not possible to assess concurrent validity of the instrument at this time. To assess the distribution of children with E/M problems across the different groups, the data for each group were put into box plot graphs. Box plots provide a graphic presentation of data in which a variety of indices of central tendency and dispersion can be observed at one time for one or more groups. (The reader is referred to Tukey, 1977, for a more detailed discussion of box plots.)
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Table II. Internal Reliability Coefficients for Different Subgroups, Clinic and Nonclinic Subjects Combined Group
n
Cronbach's Alpha
Two parents/two or more children Two parents/one child Single parent/one child Single parent/two or more children
189 34 15 28
.76 .71 .76 .58
The total eating problem scores are significantly higher, F (1, 314) = 21.19,^ < .0001, for the clinic group (Table III). Mothers of clinic children also reported a significantly higher proportion, t (311) = 4.42, p < .0001, of the items to be a problem (Table III). The mean age for the clinic and nonclinic groups is different with the clinic group being approximately 1 year older, although this did not reach statistical significance. An analysis of covariance was done with age as the covariate. There was no difference in the total CEBI scores between the younger (2 to 6 years) and older (7 to 12 years) children either between groups or within groups (Table III). Based on the mean percentage of items perceived to be a problem (i.e., 20% for the clinic group and 13% for the nonclinic group), the midpoint between the two values (16%), was taken as the cutoff point for defining the presence of an eating problem. The number of cases for which 16% or more of the items were perceived to be a problem was significantly greater for the clinic group as compared with the nonclinic group (x 2 = 16.79, p < .0001). Fifty-six percent of mothers of clinic children reported 16% or more of the items to be a problem as Table III. Total Eating Problem Scores and Percentage of Items Perceived to be a Problem for Clinic and Nonclinic Croups by Age Group Nonclinic {n = 206)
Eating problem score Total sample0 2 to 6 years old 7 to 12 years old Percentage of items perceived to be a problem Total sample" 2 to 6 years old 7 to 12 years old °p < .0001.
Clinic (n = 110)
M
SD
M
SD
86.65 88.08 83.93
11.54 11.73 10.74
92.52 93.00 92.07
12.57 14.27 10.85
13.26 13.40 12.97
13.26 13.32 13.22
20.86 19.49 22.14
16.65 17.84 15.51
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Construct Validity
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Archer, Rosenbaum and Streiner Menial Handicap
r Aullsllc
> H
Eating Problem ———7—-—
60
70
80
90
100
110
120
130
Total Eating Problem Score Fig. 1. Box plots of total eating problem scores for clinic and nonciinic groups. Key parts of a box plot include (a) the asterisk in the middle which represents the median of the distribution, (b) the ends of the box which fall at the upper and lower quartiles such that the middle 50% of the cases fall within the box, (c) lines coming out the ends, "whiskers," which show the degree of dispersion in the data, and (d) the small circles beyond the whiskers are outliers. Sample size is represented in the thickness of the box; larger samples have thicker boxes.
compared with 33% of the mothers of children in the nonciinic group. None of the identified cases in the nonciinic group had been so identified by the family doctor. Box plots of the total eating problem scores for the clinic and nonciinic groups are given in Figure 1. The results show that children with eating problems occur in almost all the groups, but with the higher scores and greater numbers of cases occurring in the mentally handicapped, autistic, and eating problem groups. The PKU group has very little dispersion in its data and very few cases with eating problems. Conversely, there is considerable variability in the data from children with a physical disability.
DISCUSSION Reliability testing shows that the CEBI is a reliable instrument. Preliminary comparisons between clinic and nonciinic samples indicating higher scores for
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Physical Hanaicap
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the clinic group confirm the construct validity of the CEBI. As well, the CEBI specifies what the specific eating problems are and how stressful they are perceived to be by the mother. Because E/M problems can be highly disruptive and distressing to children and families, an instrument that can reliably assess these problems represents a significant advance in the field. The results confirm previous reports of the high prevalence of E/M problems in both nonclinic and clinic samples. In addition, the results show that E/M problems are l'/i times more common for children from clinic populations. The high rate of eating problems in children from the nonclinic sample who had not been referred for treatment suggest the potential application of the CEBI as a screening tool for children's eating/mealtime problems. A surprising finding is that age does not appear to be a relevant factor for the occurrence of E/M problems. The results from the box plot graphs show that E/M problems occurred in most groups tested. These findings provide initial support for the transactional/systemic conceptual orientation from which the CEBI is derived. In work in progress, the CEBI is being given in conjunction with measures of child behavior and family functioning. It is anticipated that these data will help to clarify further the role of parent-child-family interactional factors in relation to the medical condition and/or developmental disorder of the child in children's E/M problems. Clinical application of the CEBI with a small number of cases has confirmed the ability of the instrument to reflect improvement in E/M problems after an intervention (Archer & Szatmari, 1990; Archer et al., 1988). The CEBI may also serve as a companion questionnaire to be given with the Children's Eating Attitudes Test (ChEAT; Maloney, McGuire, & Daniels, 1988). The ChEAT is completed by children 8 to 13 years of age and provides a measure of the child's eating attitudes. Several of the items on the ChEAT are similar or identical to those on the CEBI. A possible limitation in the present study is a selection bias in the recruitment of subjects for both the nonclinic and clinic groups. Because we did not have research personnel present in the community physicians' offices or at all the pediatric clinics, it is possible that the questionnaire was selectively offered to more compliant mothers (for both the nonclinic and clinic samples) and, in the case of the clinic group to mothers of less handicapped children. This could then serve to underestimate the prevalence of E/M problems as well as depress both scores that were derived from the CEBI. However, the fact that the rates are already so high may mean on the other hand that a response set is occurring. Perhaps E/M problems are being inflated by the presence of another more primary behavioral/developmental problem in the child and or marital/family problems. The reason for the very low internal reliability level (alpha = .58) for single parents with more than one child is not readily apparent. In future studies we intend to look at the pattern of responding (i.e., specific
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APPENDIX CEBI Child's Name
Age
/ Years
Sex M F Months
HOW OFTEN DOES THIS HAPPEN? NEVER 1
SELDOM 2
SOMETIMES 3
OFTEN 4
ALWAYS 5 Is this
a problem for you? 1. My child chews food as expected for his/her age 2. My child helps to set the table 3. My child watches TV at meals 4. I feed my child if he/she doesn't eat 5. My child takes more than half an hour to eat his/her meals
1
2
3
4
5
YES NO
1
2
3
4
5
YES NO
1
2
3
4
5
YES NO
1
2
3
4
5
YES NO
1
2
3
4
5
YES NO
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items endorsed) in a variety of clinical groups including juvenile diabetic, autistic, obese, phenylketonuric, Prader-Willi, and physically disabled. These data may help us clarify the contribution of dietary, behavioral, interactional, and physical factors to children's E/M problems. In work currently underway, we are obtaining direct observational data (e.g., videotape recordings) of family dinner times in conjunction with the CEBI for both clinic and nonclinic cases. The videotape data will serve as a measure of construct and concurrent validity for the CEBI as well as providing information about family interactional patterns in which a child does and does not have an eating problem.
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NEVER 1
SELDOM 2
SOMETIMES 3
OFTEN 4
ALWAYS 5 Is this a problem for you? YES NO
2 2
3 3
4 4
5 5
YES NO YES NO
2
3
4
5
YES NO
4
YES NO
4
YES NO
4
YES NO
4
YES NO
4
YES NO
YES NO
YES NO 4 4
YES NO YES NO
YES NO
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6. Relatives complain about my child's eating 7. My child enjoys eating 8. My child asks for food which he/she shouldn't have 9. My child feeds him/her self as expected for his/her age 10. My child gags at mealtimes 11. I feel confident my . child eats enough 12. I find our meals stressful 13. My child vomits at mealtime 14. My child takes food between meals without asking 15. My child comes to the table 1 or 2 minutes after I call 16. My child chokes at mealtimes 17. My child eats quickly 18. My child makes foods for him/her self when not allowed 19. 1 get upset when my child doesn't eat
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SOME- OFALTIMES TEN WAYS 3 4 5 Is this a problem for you?
1
2
3
4
5
YES NO
1
2
3
4
5
YES NO
1
2
3
4
5
YES NO
1
2
3
4
5
YES NO
1
2
3
4
5
YES NO
1
2
3
4
5
YES NO
1
2
3
4
5
YES NO
1
2
3
4
5
YES NO
1
2
3
4
5
YES NO
1
2
3
4
5
YES NO
IF YOU ARE A SINGLE PARENT SKIP TO NUMBER 34. 30. My child's behavior at meals upsets my spouse
1
2
3
4
5
YES NO
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20. At home my child eats food he/shouldn't have 21. My child eats foods that taste different 22. I let my child have snacks between meals if he/she doesn't eat at meals 23. My child uses cutlery as expected for his/her age 24. At friends' homes my child eats food he/she shouldn't eat 25 My child asks for food between meals 26 I get upset when I think about our meals 27 My child eats chunky foods 28 My child lets food sit in his/her mouth 29. At dinner I let my child choose the foods he/she wants from what is served
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NEV- SELER DOM 1 2
SOMETIMES 3
OFTEN 4
ALWAYS 5 Is this a problem for you? YES NO
1
2
3
4
5
YES NO
1
2
3
4
5
YES NO
1
2
3
4
5
YES NO
1
2
3
4
5
YES NO
1
2
3
4
5
YES NO
1
2
3
4
5
YES NO
1 1
2 2
3 3
4 4
5 5
YES NO YES NO
IF YOU HAVE ONLY ONE CHILD SKIP NUMBER 40. 40. My child's behavior at meals upsets our other children
1
2
3
4
5
YES NO
PLEASE CHECK TO SEE THAT YOU HAVE ANSWERED ALL THE ITEMS. HAVE YOU CIRCLED A YES OR NO FOR EACH ITEM? THANK YOU.
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31. I agree with my spouse about how much our child should eat 32. My child interrupts conversations with my spouse at meals 33. I get upset with my spouse at meals 34. My child eats when upset 35. My child says he/she is hungry 36. My child says she/he'll get fat if she/he eats too much 37. My child helps to clear the table 38. My child hides food 39. My child brings toys or books to the table
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REFERENCES
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American Psychiatric Association. (1987). Diagnostic and statistical manual of mental disorders (3rd ed., rev.). Archer, L. (1990). Childhood eating and mealtime problems: Towards a multidimensional perspective. Manuscript submitted, McMaster University. Archer, L., & Cunningham, C. E. (1988). A transactional/systemic model of childhood eating and mealtime problems: Development of an instrument [Abstract]. Developmental Medicine and Child Neurology, J0(Suppl. 57), 42. Archer, L., Cunningham, C. E., & Whelan, D. (1988). Coping with dietary therapy in phenylketonuria: a case report. Canadian Journal of Behavioural Science, 20, 461-466. Archer, L., & Szatmari, P. (1990). Assessment and treatment of food aversion in a four-year old boy: A multidimensional approach. Canadian Journal of Psychiatry, 35, 501-505. Chatoor, I., Conley, C , & Dickson, L. (1988). Food refusal after an incident of choking: A posttraumatic eating disorder. Journal of the American Academy of Child and Adolescent Psychiatry, 27. 535-540. Dahl, M., & Sundelin, C. (1986). Early feeding problems in an affluent society. I. Categories and clinical signs. Acta Paediatrica Scandinavica, 75, 370-379. Hagekull. B., & Dahl, M. (1987). Infants with and without feeding difficulties: Maternal experiences. International Journal of Eating Disorders, 6, 83-98. Hertzler, A. A. (1983). Children's food patterns—a review: 1. Food preferences and feeding problems. Journal of the American Dietetic Association. 83, 551-554. Linscheid, T. R. (1983). Ealing problems in children. In C. E. Walker & M. C. Roberts (Eds.), Handbook of clinical child psychology (pp. 616-639). New York: Wiley. Lohman, T. G. (1986). Applicability of body composition techniques and constants for children and youths. Exercise and Sport Science Review, 14. 325-357. Maloney, M. J., McGuire, J. B., & Daniels, S. R. (1988). Reliability testing of a children's version of the Eating Attitude Test. Journal of the American Academy of Child and Adolescent Psychiatry, 27, 541-543. Palmer, S., Thompson, R. J., & Linscheid, T. R. (1975). Applied behavior analysis in the treatment of childhood feeding problems. Developmental Medicine and Child Neurology, 17, 333-339. Streiner, D., & Norman, G. (1989). Health measurement scales: A practical guide to their development and use. London: Oxford Medical Publications. Tukey, J. W. (1977). Exploratory data analysis. Reading, MA: Addison-Wesley.
