Article
Parental perceptions of childhood feeding problems
Journal of Child Health Care 2015, Vol. 19(3) 392–401 ª The Author(s) 2013 Reprints and permission: sagepub.co.uk/journalsPermissions.nav DOI: 10.1177/1367493513509422 chc.sagepub.com
Lucy Harvey, Rachel Bryant-Waugh and Beth Watkins Great Ormond Street Hospital for Children NHS Foundation Trust, UK
Caroline Meyer Loughborough University, UK
Abstract Previous research suggests that parental report of children’s feeding corresponds with their child’s nutritional intake (Cooke et al., 2006; Ekstein et al., 2010). The current study aimed to determine whether there is a relationship between parental report of children’s feeding problems and their child’s nutritional intake in a non-clinical population and, in addition, to establish whether parental anxiety (Cooke et al., 2003) can predict whether parental report of feeding problems correspond with the child’s intake. Sixty-one parents of children aged two to seven years completed the parent report measure; the Behavioural Paediatric Feeding Assessment Scale as well as a food diary detailing their child’s intake, which was analysed using CompEAT nutritional software. They also completed the anxiety subscale of the Hospital Anxiety and Depression Scale. Previous findings of an association between parent report of feeding problems and child’s intake (Cooke et al., 2006) were not replicated. However, an association was found between parents’ anxiety and their reports of feeding problems. Parental anxiety was also found to independently predict whether parent report of feeding problems matched the child’s intake. Findings highlight the importance of a multifactorial approach to understanding childhood feeding difficulties. This requires replication with a clinical sample. Keywords Anxiety, feeding, intake, parent report
Introduction Feeding problems in early childhood are relatively common (Wright et al., 2007) and are reported by 20–25% of parents (Chatoor and Macaoay, 2008). Parents’ reports of children’s feeding problems, Corresponding author: Lucy Harvey, Feeding and Eating Disorders Service, Department of Child and Adolescent Mental Health, Great Ormond Street Hospital for Children NHS Foundation Trust, Great Ormond Street, London WC1N 3JH, UK. Email: [email protected]
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often in the form of parent interviews or questionnaires, have been found to be reliable, providing a valid measure of the presence or absence of feeding difficulties (Coulthard et al., 2004, Whelan and Cooper, 2000). Despite this, studies using parent report measures have yielded much variability in results. Some research has suggested that parents’ reports of feeding problems are associated with the adequacy of the child’s intake in terms of the nutritional content of their diet (Ekstein et al., 2010) as well as in terms of overall energy content (Cooke et al., 2006). Conversely, Cooke et al. (2003) found that children whose parents reported problematic feeding did not display limited intake of any food groups except for fruits and vegetables, the intake of which is often low in young children (Cockroft et al., 2005; Galloway, et al., 2003). The variability in the literature suggests further clarification is needed regarding whether parents’ reports of feeding problems are representative of their child’s intake, in terms of both the nutrient content and the overall energy of their diet. The variability in parents’ reports suggests that parents should also be considered when looking at children’s feeding (Aldridge et al, 2010; Cooke et al., 2003; Farrow and Blissett, 2006). The association between parental anxiety and children’s feeding, for example, has been well documented, with mothers of children receiving treatment for feeding problems showing elevated anxiety (Jones and Bryant-Waugh, 2013). Furthermore, within a non-clinical population, mothers who were anxious were more likely to report their infants as fussy or demanding feeders (Hellin and Waller, 1992), suggesting that parents with higher anxiety may report more problematic feeding in their child (Hatcher and Richtsmeier, 1990). Research has also suggested a relationship between parental anxiety and low intake in their child (Chatoor et al., 1988; Singer et al., 1991). This further highlights the need to establish whether parental anxiety is related to parent reports of feeding problems, the child’s intake or both. Despite parents’ reports of feeding problems being cited as reliable and valid, the variability in results (e.g. Cooke et al., 2003; Ekstein et al., 2010; Falciglia et al., 2000; Wright et al., 2007) suggests further clarification of the relationship between parents’ reports of feeding problems and the child’s intake is warranted. Moreover, within a non-clinical population, little published research has directly considered the role of parental anxiety in the context of both parent report and intake. This therefore identifies a gap in the literature for further investigation.
Aims In light of this, the current study first aimed to determine whether parents’ reports of their children’s feeding problems were reflected in the intake of their child, within a non-clinical population. Second, the study aimed to establish whether there is an association between parental anxiety and parents’ reports of feeding problems and children’s intake. Finally, the study aimed to establish whether parental anxiety could predict the correspondence between parents’ reports of feeding problems and their child’s intake. Correspondence was operationalised as whether parents’ reports are found to match the child’s intake. For example, measures of feeding could be said to correspond where parents’ reports of non-problematic feeding were reflected in their child’s adequate intake or, alternatively, where parents’ reports of problematic feeding were reflected in the child’s inadequate intake. In keeping with the findings of Ekstein et al. (2010) and Cooke et al. (2006), it was therefore hypothesised that there would be an association between parents’ reports of feeding problems and their child’s nutritional intake.
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An association between parental anxiety and both parents’ reports of feeding problems and children’s intake, respectively, was predicted in accordance with the findings of Jones and BryantWaugh (2013) and Hellin and Waller (1992). Finally, it was predicted that there would be a relationship between the correspondence of parents’ reports of feeding problems and intake and parental anxiety.
Method Design The study used a quantitative, questionnaire-based design, which allowed for within-participant comparisons of parents’ reports of children’s feeding problems and how these corresponded with the child’s intake. It also allowed for within-participant comparisons of how these measures of feeding were associated with the anxiety of the primary caregiver. The design also allowed for between-subject comparisons of anxiety scores in relation to whether or not parents’ reports corresponded with their child’s intake. A questionnaire design was chosen due to the availability of valid and reliable measures for anxiety and childhood feeding. A food diary was adopted for assessing children’s intake due to its use clinically (Nicholls et al., 2001) and in research using nonclinical populations (Falciglia et al., 2000). The study was approved by the ethics committee at Loughborough University.
Participants The sample consisted of 61 parents (2 fathers and 59 mothers) of children aged 2–7 years (34 male and 27 female; mean age 4.23 years, SD ¼ 1.83) who were self-selected from a pool of three consenting state primary schools and via an online link to the questionnaires. At least 46 participants were needed in order to detect a medium effect size of .36 with a power of .8 (Cohen, 1988). Participants were included if they had a child aged between two and seven years, in order to ensure they were of an age at which they were able to self-feed but would not yet be eating independently. An acceptable level of English was also required in order to complete the questionnaires. Participants were excluded from the study if their child had received treatment for a feeding disorder or if their child was outside the two- to seven-year age range. A total of 360 parents were approached in this way, and the response rate was initially low. An additional 10 participants were therefore recruited through convenience sampling by approaching parents, including teachers who were parents themselves, at a school parents’ evening.
Measures Behavioural Paediatric Feeding Assessment Scale. Parents’ reports of feeding problems were measured using the Behavioural Paediatric Feeding Assessment Scale (BPFAS; Crist and Napier-Phillips, 2001), a 35-item questionnaire completed by the parent or primary caregiver. For the current study, the total score was analysed. A score of 92 or above has been suggested to indicate a clinically significant feeding problem (Dovey at al., 2010). The questionnaire is validated for children from nine months to seven years of age and has acceptable psychometric properties (Crist and NapierPhillips, 2001).
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Hospital Anxiety and Depression Scale. Parents’ anxiety was measured using the anxiety subscale of the Hospital Anxiety and Depression Scale (HADS; Zigmond and Snaith, 1983). This 14-item selfreport questionnaire is widely used with non-clinical samples (Crawford et al., 2001). Responses are scored on a scale of 0–3 ranging, for example, from ‘not at all’ to ‘most of the time’, with scores of above 8 signifying mild disturbance and those above 16 signifying severe cases of anxiety (Snaith and Zigmond, 1994). The psychometric properties for this measure are good (Bjelland et al., 2002; Spinhoven et al., 1997). Food diary. Children’s intake was assessed using food diaries completed by the primary caregiver. This procedure follows clinical practice (Nicholls et al., 2001) and has been adopted as a research tool for non-clinical populations (Falciglia et al., 2000). Instructions for the diary asked caregivers to detail one ‘average day’ of their child’s intake, as recommended by the Food Standards Agency (2008) and used in previous research (Harnack et al., 2004). This option was chosen in order to retain participants with time constraints or those who could not monitor their child’s intake, for example, on a school day. The food diary data were analysed using the nutritional programme CompEAT (Nutrition Systems in association with VIS Visual Information Systems Ltd.), which calculates the child’s total energy intake and the nutritional breakdown of the child’s diet based on individuals’ age, weight and height. Upon dietetic advice, the recommended nutrient intake (RNI) percentage was used to determine whether the child’s intake was adequate. This score was calculated by generating a mean percentage of the five nutrients, protein, carbohydrate, fat, iron and calcium, and then calculating a combined mean from this score and the child’s total energy intake. If the RNI percentage was above 80%, the child’s diet was deemed nutritionally adequate (Department of Health, 1991). Demographic questionnaire. A short demographic questionnaire was designed for parents to complete to obtain information about the sample, including participants’ ethnicity, occupation and education, any previous feeding or eating treatment received by the parent or child and the child’s weight and height.
Procedure Initially, 12 primary schools were approached, in writing, informing head teachers about the study and requesting consent. The three consenting schools were then visited and provided with sufficient questionnaire packs for all pupils in reception (four–five years), year one (five–six years) and year two classes (six–seven years). Participants returned completed packs and consent forms, in the envelope provided, to the school with their child. Alternatively, participants were given the option to complete the questionnaires via an online link.
Data analysis The data were found to be normally distributed and therefore parametric tests were used. An a level of .05 was adopted throughout as this was deemed to be an appropriate level of confidence to limit the likelihood of type I errors. All tests were two-tailed in accordance with the hypotheses. First, a Pearson’s product moment correlation was carried out on parents’ reports of their child’s feeding problems and child’s intake, as measured by the BPFAS total scores and RNI percentage
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Table 1. Means and SDs for children’s age, weight for height and percentage of RNI, parents’ BPFAS total score and HADS anxiety scores. Mean + SD Child age Weight for height BPFAS total Percentage RNI HADS anxiety
Male (N ¼ 34) 4.29 + 99.58 + 58.76 + 138.88 + 7.41 +
1.96 20.92 15.17 41.20 3.78
Female (N ¼ 27) 4.15 105.59 63.19 135.91 6.04
Total (N ¼ 61)
+ 1.68 + 27.04 + 15.23 + 24.82 + 3.26
4.23 + 102.31 + 60.72 + 137.57 + 6.80 +
1.83 23.80 15.23 34.68 3.60
RNI: recommended nutritional intake; BPFAS: Behavioural Paediatric Feeding Assessment Scale; HADS: Hospital Anxiety and Depression Scale.
Table 2. Means and SDs for HADS anxiety scores in terms of the correspondence of parents’ reports of feeding problems and children’s intake.
Mean + SD HADS anxiety
Correspondence between subjective and objective measures (N ¼ 55)
Non-correspondence between subjective and objective measures (N ¼ 6)
6.42 + 3.53*
10.33 + 2.07*
HADS: Hospital Anxiety and Depression Scale. *Indicates a significant result at p < 0.05.
generated from analysed food diaries, respectively. Second, Pearson’s correlations were carried out on parents’ BPFAS and HADS anxiety scores and then on RNI percentages and HADS anxiety scores. Finally, a logistic regression analysis was carried out to assess the degree to which parents’ anxiety scores predicted the correspondence between parents’ reports of feeding problems and children’s intake. Correspondence referred to instances where BPFAS scores below the clinical cut-off of 92 were paired with RNI above 80%, representing nutritional adequacy. Reports were also said to correspond if BPFAS scores were above the clinical cut-off of 92 and the child’s RNI was below 80%, representing inadequate intake. This analysis was chosen as correspondence, and non-correspondence was operationalised categorically. All data were analysed using PASW v18 (IBM).
Results Tables 1 and 2 show the descriptive statistics obtained from participants and their children after dealing with outliers. Five children scored within the clinical range on BPFAS scores, and only one child’s food diary reported an intake of below the 80% RNI nutritional cut-off. This highlights that the majority of the sample did not have clinically significant feeding difficulties and most had a nutritionally adequate diet. Hypothesis 1: Correlation between parents’ subjective reports of their child’s feeding and objective measures of intake. There was a non-significant positive correlation between BPFAS total score and percentage of RNI (r ¼ .118, N ¼ 61, p ¼ .365 (two-tailed). Parents’ reports of feeding problems were therefore not found to be associated with children’s intake.
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Table 3. Correlation between parents’ reports of children’s feeding problems and children’s intake and HADS anxiety scores.
BPFAS total (N ¼ 61) HADS anxiety (N ¼ 61)
Pearson’s correlation Sig. (two-tailed) Pearson’s correlation Sig. (two-tailed)
BPFAS scores
Percentage RNI
.118 .365 .315* .013*
.161 .216
RNI: recommended nutritional intake; BPFAS: Behavioural Paediatric Feeding Assessment Scale; HADS: Hospital Anxiety and Depression Scale. *Indicates a significant result at p < 0.05.
Hypothesis 2: Correlation between children’s feeding and parental anxiety. There was a significant positive correlation between BPFAS total scores and HADS anxiety scores (r ¼ .315, N ¼ 61, p < .05; two-tailed). Reports of more problematic feeding, as indicated by higher BPFAS total scores, were associated with higher parental anxiety. However, there was found to be a non-significant correlation between percentage of RNI and HADS anxiety scores (r ¼ 0.161, N ¼ 61, p ¼ .216; two-tailed). Therefore, parental anxiety was found to be associated with parent report of feeding problems but not with children’s intake (Table 3). Hypothesis 3: Predictors of the correspondence between subjective and objective reports of feeding. A model based on HADS anxiety scores was significantly accurate in predicting correspondence between reports ( 2(1) ¼ 6.44, p < .05). This model correctly predicted group membership of 90.2% of the cases. Therefore, anxiety was found to be independently predictive of the correspondence between parents’ reports of feeding problems and children’s intake, in that parents whose reports of feeding problems did not match the child’s intake, for example, where reports of feeding problems were not reflected in inadequate intake, were found to have higher anxiety. For the purpose of the current study, HADS depression scores were not used.
Discussion This study aimed first to replicate previous findings of an association between parents’ reports of feeding problems and children’s intake (Cooke et al., 2006; Ekstein et al., 2010) within a non-clinical sample. Findings did not support the first hypothesis. The non-significant correlation suggests parents’ reports of feeding problems were not associated with their child’s intake within the current non-clinical population, therefore suggesting that neither should be looked at in isolation when attempting to determine whether a child’s feeding is problematic. Although this correlation was non-significant, the relationship between these two variables was found to be positive with those displaying higher BPFAS scores, indicating more problematic feeding, also displaying higher nutritional intake. This was not anticipated as higher BPFAS scores were expected to correspond with lower nutritional intake. Repeating the analysis with a larger sample size may help to either contradict this finding or to verify it, thus highlighting the need to further investigate factors that may contribute to the relationship between parents’ reports of feeding and children’s intake.
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Second, the study aimed to replicate findings, found in both clinical and non-clinical samples, of an association between children’s feeding and parental anxiety (Hellin and Waller, 1992; Jones and Bryant-Waugh, 2013). Findings partially supported the second hypothesis. Specifically, higher parental anxiety was associated with parents’ reports of feeding problems. However, there was a non-significant relationship between children’s intake and parental anxiety, despite previous research suggesting low intake to be associated with anxiety in parents (Singer et al., 1991). A possible explanation for this could be that within a non-clinical group, parents’ worries about their child’s feeding may be based upon low consumption of new foods (Wright et al., 2007) or certain food groups, such as fruits and vegetables (Cockroft et al., 2005; Cooke et al., 2003) and could cause parents to believe that their child’s feeding is problematic in that it contradicts their perceptions of healthy eating (Kessler et al., 2010). This further indicates the need for adopting a multifactorial approach to feeding problems as considering nutrition in isolation may not capture the perception of the feeding problems from the parents’ perspective. Within clinical samples of children with feeding problems, however, it may be more likely that children are nutritionally compromised, as suggested by diagnostic criteria (American Psychological Society (APA), 2000), and this in itself may constitute a cause for parental concern. This study should be replicated within a clinical sample to establish whether this is the case, thus differing from a non-clinical sample. Finally, the study aimed to further extend previous findings of a relationship between feeding and anxiety by establishing whether parents’ anxiety could predict the correspondence between parents’ reports of feeding problems and children’s intake. Correspondence referred to whether parents’ reports of feeding problems were reflected in the child’s inadequate intake. For example, non-correspondence therefore referred to parents reporting problematic feeding, where their child’s intake was adequate. The third hypothesis was supported by the study’s findings, as anxiety was found to predict whether parents’ reports of feeding problems corresponded with the child’s intake. Specifically, parents whose reports did not correspond with their child’s intake had higher anxiety. To date, little research had considered the role of parents’ anxiety in terms of whether parents’ reports of feeding problems correspond with the child’s intake. Within the current sample, however, very few parents’ reports did not correspond with intake. This is potentially due to the nonclinical population, as it is unlikely that the children’s feeding would be particularly problematic. The current study provides an initial exploration of the relationship between parent report of feeding, children’s intake and parental anxiety. However, although no statistical assumptions were violated by the unequal group size, future research should include a larger non-clinical sample and a clinical sample for comparison, in order to establish whether results from the current study are generalisable across clinical and non-clinical populations. Furthermore, although higher anxiety was found to predict non-correspondence between parents’ reports of feeding problems and children’s intake, the non-correspondence group in this study consisted both of parents whose reports of feeding problems were coupled with adequate intake in their child and of parents whose reports of normal feeding were coupled with low intake; the latter is not supported by the literature and requires further consideration. However, within a clinical sample, this would be expected to occur less frequently, as parents will have reported a feeding problem in their child in order to be seen clinically. Thus, the non-correspondence group would be expected to consist only of parents whose reports of a problem are not reflected in inadequate intake. This again supports the need to investigate this relationship further, with the inclusion of a clinical group.
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A potential confounder in the analysis might be children’s weights. Recent literature has explored parents’ concerns about their children’s weights in relation to children’s intake (BossinkTuna et al., 2009). Weight therefore represents a further factor to consider in future research. The current study had some limitations. First, participants in the current study were selfselected. This may represent a bias in the sample, potentially attracting a higher proportion of parents with concerns or anxiety associated with their child’s feeding. Furthermore, the measure of intake could potentially have been problematic as, although previous studies have used food diaries as measures of intake (Falciglia et al., 2001) and the food diary data were analysed objectively, using CompEAT, the diary itself was completed by the parent and therefore comprised of a subjective element. It was therefore subject to inaccurate reports in terms of amounts, with the potential to underestimate (Hill and Davies, 2001). If parents’ completion of food diaries was inaccurate, the analysis of the child’s intake would also not have represented an accurate objective measure of intake. Furthermore, the current study asked parents to detail their child’s eating on a ‘typical’ day in an attempt to increase response rates by reducing the time burdens upon parents as a result of filling in the diary over a longer period. In order to glean a more accurate and robust indication of children’s intake, future research utilising a food diary method might consider asking parents to complete a minimum of a three-day diary. The food diary method is also subject to social desirability bias as parents may wish to be seen to be providing their child with a balanced diet (Hanson et al., 2005), especially as healthy eating is widely encouraged in schools (Shepherd et al., 2006), from which participants in the current study were recruited. Despite its flaws, this method was deemed to be the most convenient and appropriate method for the current study. A further limitation of the current study is its small sample size and the very small proportion of participants whose children were reported to display problematic feeding behaviour. As a result, current findings could not be meaningfully generalised to the wider population or applied to a sample of children with clinically significant feeding problems. It does, however, provide an initial investigation of parents’ reports of feeding and intake, along with the relationship with parental anxiety, in a non-clinical population. Previous research has not been able to determine causality in the relationship between children’s feeding and parental anxiety (Coulthard and Harris, 2003). Similarly, as correlations were used in the current study, causality was again not established; presenting another limitation of this study. This should therefore be considered in future work. The current research has further evidenced anxiety as a factor associated with parents’ reports of feeding problems, in line with previous research (Hellin and Waller, 1992; Jones and Bryant-Waugh, 2013). This finding, within a non-clinical population, may have implications in terms of the information available to parents regarding their children’s feeding and nutrition, including what constitutes ‘problematic’ eating and what remains within a normal spectrum. Interventions may be necessary to reassure parents that ‘normal’ eating can look different to each individual (Birch, 1999). In conclusion, this study did not replicate previous findings of an association between parents’ reports of feeding problems and children’s intake and therefore highlights the importance of a multifactorial approach to understanding reported child feeding difficulties. Much research has focused on nutritional intake in isolation and this study has suggested that this alone may not be able to adequately define a child’s feeding problem. The current study was able to provide an extension to the literature regarding the role of anxiety in parental reports of feeding problems. In particular, findings that parental anxiety could predict the correspondence between parents’ reports and children’s intake in the current sample raised questions regarding the appropriateness of relying upon nutritional information alone where
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parents have higher levels of anxiety. However, as the full extent and causality of this relationship was not established in the current study, further investigation is necessary in this area. Conflict of interest The authors declared no conflicts of interest. Funding This research received no specific grant from any funding agency in the public, commercial or not-for-profit sectors. References Aldridge VK, Dovey TM, Martin CI and Meyer C (2010) Identifying clinically relevant feeding problems and disorders. Journal of Child Health Care 14(3): 261–270. American Psychiatric Association (APA) (2000) DSM IV-TR: Diagnostic and Statistical Manual Mental Disorders: Text Revision. Washington, DC: American Psychiatric Association. Birch LL (1999) Development of food preferences. Annual Review of Nutrition 19(1): 41–62. Bossink-Tuna HN, L’hoir MP, Beltman M and Boere-Boonekamp MM (2009) Parental perception of weight and weight-related behaviour in 2-to 4-year-old children in the eastern part of the Netherlands. European Journal of Pediatrics 168(3): 333–339. Bjelland I, Dahl AA, Haug TT and Neckelmann D (2002) The validity of the hospital anxiety and depression scale: An updated literature review. Journal of Psychosomatic Research 52(2): 69–77. Chatoor I, Conley C and 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(1): 105–110. Chatoor I and Macaoay M (2008) Feeding development and disorders. In: MM Haith and JB Benson (eds) Encyclopedia of Infant and Early Childhood Development. New York, NY: Academic Press, pp. 524–533. Cockroft JE, Durkin M, Masding C and Cade JE (2005) Fruit and vegetable intakes in a sample of preschool children participating in the ‘Five for All’ project in Bradford. Public Health Nutrition 8(07): 861–869. Cohen J (1988) Statistical Power Analysis for the Behavioral Sciences. New York, NY: Academic Press. Cooke L, Carnell S and Wardle J (2006) Food neophobia and mealtime food consumption in 4–5 year old children. International Journal of Behavioral Nutrition and Physical Activity 3(1): 1–6. Cooke L, Wardle J and Gibson EL (2003) Relationship between parental report of food neophobia and everyday food consumption in 2–6 year old children. Appetite 41(2): 205–206. Coulthard H, Blissett J and Harris G (2004) The relationship between parental eating problems and children’s feeding behavior: A selective review of the literature. Eating Behaviors 5(2): 103–115. Coulthard H and Harris G (2003) Early food refusal: The role of maternal mood. Journal of Reproductive and Infant Psychology 21(4): 335–345. Crawford JR, Henry JD, Crombie C and Taylor EP (2001) Normative data for the HADS from a large nonclinical sample. The British Journal of Clinical Psychology 40(Pt 4): 429–434. Crist W and Napier-Phillips A (2001) Mealtime behaviors of young children: A comparison of normative and clinical data. Journal of Developmental and Behavioral Pediatrics 22(5): 279–286. Department of Health (1991) Dietary reference values for food, energy and nutrients for the United Kingdom. Report on Health and Social Subjects 41: 174–177. Dovey TM, Isherwood E, Aldridge VK and Martin CI (2010) Typology of feeding disorders based on a single assessment system: Formulation of a clinical decision-making model. Infant, Child, and Adolescent Nutrition 2(1): 45–51.
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Ekstein S, Laniado D and Glick B (2010) Does picky eating affect weight-for-length measurements in young children? Clinical Pediatrics 49(3): 217–220. Falciglia GA, Couch SC, Gribble LS, Pabst SM and Frank R (2000) Food neophobia in childhood affects dietary variety. Journal of the American Dietetic Association 100(12): 1474–1481. Farrow C and Blissett J (2006) Maternal cognitions, psychopathologic symptoms, and infant temperament as predictors of early infant feeding problems: A longitudinal study. International Journal of Eating Disorders 39(2): 128–134. Food Standards Agency (2008) Manual of Nutrition. London, UK: The Stationary Office. Galloway AT, Lee Y and Birch LL (2000) Predictors and consequences of food neophobia and pickiness in young girls. Journal of the American Dietetic Association 103(6): 692–698. Hanson NI, Neumark-Sztainer D, Eisenberg ME, Story M and Wall M (2005) Associations between parental report of the home food environment and adolescent intakes of fruits, vegetables and dairy foods. Public Health Nutrition 8(01): 77–85. Harnack L, Himes JH, Anliker J, Clay T, Gittelsohn J, Jobe JB, et al. (2004) Intervention-related bias in reporting of food intake by fifth-grade children participating in an obesity prevention study. American Journal of Epidemiology 160(11): 1117–1121. Hatcher JW and Richtsmeier AJ (1990) Parent anxiety and satisfaction with a pediatric visit. Medical Care 28(10): 978–981. Hellin K and Waller G (1992) Mothers’ mood and infant feeding: Prediction of problems and practices. Journal of Reproductive and Infant Psychology 10(1): 39–51. Hill RJ and Davies PS (2001) The validity of self-reported energy intake as determined using the doubly labelled water technique. The British Journal of Nutrition 85(4): 415–430. Jones C and Bryant-Waugh R (2013) The relationship between child feeding problems and maternal mental health: A selective review. Advances in Eating Disorders 1: 119–133. Kessler DB, Fortune EL, Werner EG and Stein MT (2010) 11 month-old twins with food avoidance. Journal of Developmental and Behavioral Pediatrics 31(3): S112–S116. Nicholls D, Christie D, Randall L and Lask B (2001) Selective eating: Symptom, disorder or normal variant. Clinical Child Psychology and Psychiatry 6(2): 257–270. Shepherd J, Harden A, Rees R, Brunton G, Garcia J, Oliver S, et al. (2006) Young people and healthy eating: A systematic review of research on barriers and facilitators. Health Education Research 21(2): 239–257. Singer LT, Nofer JA, Benson-Szekely LJ and Brooks LJ (1991) Behavioral assessment and management of food refusal in children with systic fibrosis. Journal of Developmental and Behavioral Pediatrics 12(2): 115–120. Snaith RP and Zigmond AS (1994) HADS: Hospital Anxiety and Depression Scale. Windsor, Canada: NFER Nelson. Spinhoven P, Ormel J, Sloekers PP, Kempen GI, Speckens AE and Van Hemert AM (1997) A validation study of the hospital anxiety and depression scale (HADS) in different groups of Dutch subjects. Psychological Medicine 27(2): 363–370. Whelan E and Cooper PJ (2000) The association between childhood feeding problems and maternal eating disorder: A community study. Psychological Medicine 30(01): 69–77. Wright CM, Parkinson KN, Shipton D and Drewett RF (2007) How do toddler eating problems relate to their eating behavior, food preferences, and growth? Pediatrics 120(4): e1069–e1075. Zigmond AS and Snaith RP (1983) The hospital anxiety and depression scale. Acta Psychiatrica Scandinavica 67(6): 361–370.
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Parental perceptions of childhood feeding problems
Journal of Child Health Care 2015, Vol. 19(3) 392–401 ª The Author(s) 2013 Reprints and permission: sagepub.co.uk/journalsPermissions.nav DOI: 10.1177/1367493513509422 chc.sagepub.com
Lucy Harvey, Rachel Bryant-Waugh and Beth Watkins Great Ormond Street Hospital for Children NHS Foundation Trust, UK
Caroline Meyer Loughborough University, UK
Abstract Previous research suggests that parental report of children’s feeding corresponds with their child’s nutritional intake (Cooke et al., 2006; Ekstein et al., 2010). The current study aimed to determine whether there is a relationship between parental report of children’s feeding problems and their child’s nutritional intake in a non-clinical population and, in addition, to establish whether parental anxiety (Cooke et al., 2003) can predict whether parental report of feeding problems correspond with the child’s intake. Sixty-one parents of children aged two to seven years completed the parent report measure; the Behavioural Paediatric Feeding Assessment Scale as well as a food diary detailing their child’s intake, which was analysed using CompEAT nutritional software. They also completed the anxiety subscale of the Hospital Anxiety and Depression Scale. Previous findings of an association between parent report of feeding problems and child’s intake (Cooke et al., 2006) were not replicated. However, an association was found between parents’ anxiety and their reports of feeding problems. Parental anxiety was also found to independently predict whether parent report of feeding problems matched the child’s intake. Findings highlight the importance of a multifactorial approach to understanding childhood feeding difficulties. This requires replication with a clinical sample. Keywords Anxiety, feeding, intake, parent report
Introduction Feeding problems in early childhood are relatively common (Wright et al., 2007) and are reported by 20–25% of parents (Chatoor and Macaoay, 2008). Parents’ reports of children’s feeding problems, Corresponding author: Lucy Harvey, Feeding and Eating Disorders Service, Department of Child and Adolescent Mental Health, Great Ormond Street Hospital for Children NHS Foundation Trust, Great Ormond Street, London WC1N 3JH, UK. Email: [email protected]
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often in the form of parent interviews or questionnaires, have been found to be reliable, providing a valid measure of the presence or absence of feeding difficulties (Coulthard et al., 2004, Whelan and Cooper, 2000). Despite this, studies using parent report measures have yielded much variability in results. Some research has suggested that parents’ reports of feeding problems are associated with the adequacy of the child’s intake in terms of the nutritional content of their diet (Ekstein et al., 2010) as well as in terms of overall energy content (Cooke et al., 2006). Conversely, Cooke et al. (2003) found that children whose parents reported problematic feeding did not display limited intake of any food groups except for fruits and vegetables, the intake of which is often low in young children (Cockroft et al., 2005; Galloway, et al., 2003). The variability in the literature suggests further clarification is needed regarding whether parents’ reports of feeding problems are representative of their child’s intake, in terms of both the nutrient content and the overall energy of their diet. The variability in parents’ reports suggests that parents should also be considered when looking at children’s feeding (Aldridge et al, 2010; Cooke et al., 2003; Farrow and Blissett, 2006). The association between parental anxiety and children’s feeding, for example, has been well documented, with mothers of children receiving treatment for feeding problems showing elevated anxiety (Jones and Bryant-Waugh, 2013). Furthermore, within a non-clinical population, mothers who were anxious were more likely to report their infants as fussy or demanding feeders (Hellin and Waller, 1992), suggesting that parents with higher anxiety may report more problematic feeding in their child (Hatcher and Richtsmeier, 1990). Research has also suggested a relationship between parental anxiety and low intake in their child (Chatoor et al., 1988; Singer et al., 1991). This further highlights the need to establish whether parental anxiety is related to parent reports of feeding problems, the child’s intake or both. Despite parents’ reports of feeding problems being cited as reliable and valid, the variability in results (e.g. Cooke et al., 2003; Ekstein et al., 2010; Falciglia et al., 2000; Wright et al., 2007) suggests further clarification of the relationship between parents’ reports of feeding problems and the child’s intake is warranted. Moreover, within a non-clinical population, little published research has directly considered the role of parental anxiety in the context of both parent report and intake. This therefore identifies a gap in the literature for further investigation.
Aims In light of this, the current study first aimed to determine whether parents’ reports of their children’s feeding problems were reflected in the intake of their child, within a non-clinical population. Second, the study aimed to establish whether there is an association between parental anxiety and parents’ reports of feeding problems and children’s intake. Finally, the study aimed to establish whether parental anxiety could predict the correspondence between parents’ reports of feeding problems and their child’s intake. Correspondence was operationalised as whether parents’ reports are found to match the child’s intake. For example, measures of feeding could be said to correspond where parents’ reports of non-problematic feeding were reflected in their child’s adequate intake or, alternatively, where parents’ reports of problematic feeding were reflected in the child’s inadequate intake. In keeping with the findings of Ekstein et al. (2010) and Cooke et al. (2006), it was therefore hypothesised that there would be an association between parents’ reports of feeding problems and their child’s nutritional intake.
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An association between parental anxiety and both parents’ reports of feeding problems and children’s intake, respectively, was predicted in accordance with the findings of Jones and BryantWaugh (2013) and Hellin and Waller (1992). Finally, it was predicted that there would be a relationship between the correspondence of parents’ reports of feeding problems and intake and parental anxiety.
Method Design The study used a quantitative, questionnaire-based design, which allowed for within-participant comparisons of parents’ reports of children’s feeding problems and how these corresponded with the child’s intake. It also allowed for within-participant comparisons of how these measures of feeding were associated with the anxiety of the primary caregiver. The design also allowed for between-subject comparisons of anxiety scores in relation to whether or not parents’ reports corresponded with their child’s intake. A questionnaire design was chosen due to the availability of valid and reliable measures for anxiety and childhood feeding. A food diary was adopted for assessing children’s intake due to its use clinically (Nicholls et al., 2001) and in research using nonclinical populations (Falciglia et al., 2000). The study was approved by the ethics committee at Loughborough University.
Participants The sample consisted of 61 parents (2 fathers and 59 mothers) of children aged 2–7 years (34 male and 27 female; mean age 4.23 years, SD ¼ 1.83) who were self-selected from a pool of three consenting state primary schools and via an online link to the questionnaires. At least 46 participants were needed in order to detect a medium effect size of .36 with a power of .8 (Cohen, 1988). Participants were included if they had a child aged between two and seven years, in order to ensure they were of an age at which they were able to self-feed but would not yet be eating independently. An acceptable level of English was also required in order to complete the questionnaires. Participants were excluded from the study if their child had received treatment for a feeding disorder or if their child was outside the two- to seven-year age range. A total of 360 parents were approached in this way, and the response rate was initially low. An additional 10 participants were therefore recruited through convenience sampling by approaching parents, including teachers who were parents themselves, at a school parents’ evening.
Measures Behavioural Paediatric Feeding Assessment Scale. Parents’ reports of feeding problems were measured using the Behavioural Paediatric Feeding Assessment Scale (BPFAS; Crist and Napier-Phillips, 2001), a 35-item questionnaire completed by the parent or primary caregiver. For the current study, the total score was analysed. A score of 92 or above has been suggested to indicate a clinically significant feeding problem (Dovey at al., 2010). The questionnaire is validated for children from nine months to seven years of age and has acceptable psychometric properties (Crist and NapierPhillips, 2001).
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Hospital Anxiety and Depression Scale. Parents’ anxiety was measured using the anxiety subscale of the Hospital Anxiety and Depression Scale (HADS; Zigmond and Snaith, 1983). This 14-item selfreport questionnaire is widely used with non-clinical samples (Crawford et al., 2001). Responses are scored on a scale of 0–3 ranging, for example, from ‘not at all’ to ‘most of the time’, with scores of above 8 signifying mild disturbance and those above 16 signifying severe cases of anxiety (Snaith and Zigmond, 1994). The psychometric properties for this measure are good (Bjelland et al., 2002; Spinhoven et al., 1997). Food diary. Children’s intake was assessed using food diaries completed by the primary caregiver. This procedure follows clinical practice (Nicholls et al., 2001) and has been adopted as a research tool for non-clinical populations (Falciglia et al., 2000). Instructions for the diary asked caregivers to detail one ‘average day’ of their child’s intake, as recommended by the Food Standards Agency (2008) and used in previous research (Harnack et al., 2004). This option was chosen in order to retain participants with time constraints or those who could not monitor their child’s intake, for example, on a school day. The food diary data were analysed using the nutritional programme CompEAT (Nutrition Systems in association with VIS Visual Information Systems Ltd.), which calculates the child’s total energy intake and the nutritional breakdown of the child’s diet based on individuals’ age, weight and height. Upon dietetic advice, the recommended nutrient intake (RNI) percentage was used to determine whether the child’s intake was adequate. This score was calculated by generating a mean percentage of the five nutrients, protein, carbohydrate, fat, iron and calcium, and then calculating a combined mean from this score and the child’s total energy intake. If the RNI percentage was above 80%, the child’s diet was deemed nutritionally adequate (Department of Health, 1991). Demographic questionnaire. A short demographic questionnaire was designed for parents to complete to obtain information about the sample, including participants’ ethnicity, occupation and education, any previous feeding or eating treatment received by the parent or child and the child’s weight and height.
Procedure Initially, 12 primary schools were approached, in writing, informing head teachers about the study and requesting consent. The three consenting schools were then visited and provided with sufficient questionnaire packs for all pupils in reception (four–five years), year one (five–six years) and year two classes (six–seven years). Participants returned completed packs and consent forms, in the envelope provided, to the school with their child. Alternatively, participants were given the option to complete the questionnaires via an online link.
Data analysis The data were found to be normally distributed and therefore parametric tests were used. An a level of .05 was adopted throughout as this was deemed to be an appropriate level of confidence to limit the likelihood of type I errors. All tests were two-tailed in accordance with the hypotheses. First, a Pearson’s product moment correlation was carried out on parents’ reports of their child’s feeding problems and child’s intake, as measured by the BPFAS total scores and RNI percentage
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Table 1. Means and SDs for children’s age, weight for height and percentage of RNI, parents’ BPFAS total score and HADS anxiety scores. Mean + SD Child age Weight for height BPFAS total Percentage RNI HADS anxiety
Male (N ¼ 34) 4.29 + 99.58 + 58.76 + 138.88 + 7.41 +
1.96 20.92 15.17 41.20 3.78
Female (N ¼ 27) 4.15 105.59 63.19 135.91 6.04
Total (N ¼ 61)
+ 1.68 + 27.04 + 15.23 + 24.82 + 3.26
4.23 + 102.31 + 60.72 + 137.57 + 6.80 +
1.83 23.80 15.23 34.68 3.60
RNI: recommended nutritional intake; BPFAS: Behavioural Paediatric Feeding Assessment Scale; HADS: Hospital Anxiety and Depression Scale.
Table 2. Means and SDs for HADS anxiety scores in terms of the correspondence of parents’ reports of feeding problems and children’s intake.
Mean + SD HADS anxiety
Correspondence between subjective and objective measures (N ¼ 55)
Non-correspondence between subjective and objective measures (N ¼ 6)
6.42 + 3.53*
10.33 + 2.07*
HADS: Hospital Anxiety and Depression Scale. *Indicates a significant result at p < 0.05.
generated from analysed food diaries, respectively. Second, Pearson’s correlations were carried out on parents’ BPFAS and HADS anxiety scores and then on RNI percentages and HADS anxiety scores. Finally, a logistic regression analysis was carried out to assess the degree to which parents’ anxiety scores predicted the correspondence between parents’ reports of feeding problems and children’s intake. Correspondence referred to instances where BPFAS scores below the clinical cut-off of 92 were paired with RNI above 80%, representing nutritional adequacy. Reports were also said to correspond if BPFAS scores were above the clinical cut-off of 92 and the child’s RNI was below 80%, representing inadequate intake. This analysis was chosen as correspondence, and non-correspondence was operationalised categorically. All data were analysed using PASW v18 (IBM).
Results Tables 1 and 2 show the descriptive statistics obtained from participants and their children after dealing with outliers. Five children scored within the clinical range on BPFAS scores, and only one child’s food diary reported an intake of below the 80% RNI nutritional cut-off. This highlights that the majority of the sample did not have clinically significant feeding difficulties and most had a nutritionally adequate diet. Hypothesis 1: Correlation between parents’ subjective reports of their child’s feeding and objective measures of intake. There was a non-significant positive correlation between BPFAS total score and percentage of RNI (r ¼ .118, N ¼ 61, p ¼ .365 (two-tailed). Parents’ reports of feeding problems were therefore not found to be associated with children’s intake.
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Table 3. Correlation between parents’ reports of children’s feeding problems and children’s intake and HADS anxiety scores.
BPFAS total (N ¼ 61) HADS anxiety (N ¼ 61)
Pearson’s correlation Sig. (two-tailed) Pearson’s correlation Sig. (two-tailed)
BPFAS scores
Percentage RNI
.118 .365 .315* .013*
.161 .216
RNI: recommended nutritional intake; BPFAS: Behavioural Paediatric Feeding Assessment Scale; HADS: Hospital Anxiety and Depression Scale. *Indicates a significant result at p < 0.05.
Hypothesis 2: Correlation between children’s feeding and parental anxiety. There was a significant positive correlation between BPFAS total scores and HADS anxiety scores (r ¼ .315, N ¼ 61, p < .05; two-tailed). Reports of more problematic feeding, as indicated by higher BPFAS total scores, were associated with higher parental anxiety. However, there was found to be a non-significant correlation between percentage of RNI and HADS anxiety scores (r ¼ 0.161, N ¼ 61, p ¼ .216; two-tailed). Therefore, parental anxiety was found to be associated with parent report of feeding problems but not with children’s intake (Table 3). Hypothesis 3: Predictors of the correspondence between subjective and objective reports of feeding. A model based on HADS anxiety scores was significantly accurate in predicting correspondence between reports ( 2(1) ¼ 6.44, p < .05). This model correctly predicted group membership of 90.2% of the cases. Therefore, anxiety was found to be independently predictive of the correspondence between parents’ reports of feeding problems and children’s intake, in that parents whose reports of feeding problems did not match the child’s intake, for example, where reports of feeding problems were not reflected in inadequate intake, were found to have higher anxiety. For the purpose of the current study, HADS depression scores were not used.
Discussion This study aimed first to replicate previous findings of an association between parents’ reports of feeding problems and children’s intake (Cooke et al., 2006; Ekstein et al., 2010) within a non-clinical sample. Findings did not support the first hypothesis. The non-significant correlation suggests parents’ reports of feeding problems were not associated with their child’s intake within the current non-clinical population, therefore suggesting that neither should be looked at in isolation when attempting to determine whether a child’s feeding is problematic. Although this correlation was non-significant, the relationship between these two variables was found to be positive with those displaying higher BPFAS scores, indicating more problematic feeding, also displaying higher nutritional intake. This was not anticipated as higher BPFAS scores were expected to correspond with lower nutritional intake. Repeating the analysis with a larger sample size may help to either contradict this finding or to verify it, thus highlighting the need to further investigate factors that may contribute to the relationship between parents’ reports of feeding and children’s intake.
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Second, the study aimed to replicate findings, found in both clinical and non-clinical samples, of an association between children’s feeding and parental anxiety (Hellin and Waller, 1992; Jones and Bryant-Waugh, 2013). Findings partially supported the second hypothesis. Specifically, higher parental anxiety was associated with parents’ reports of feeding problems. However, there was a non-significant relationship between children’s intake and parental anxiety, despite previous research suggesting low intake to be associated with anxiety in parents (Singer et al., 1991). A possible explanation for this could be that within a non-clinical group, parents’ worries about their child’s feeding may be based upon low consumption of new foods (Wright et al., 2007) or certain food groups, such as fruits and vegetables (Cockroft et al., 2005; Cooke et al., 2003) and could cause parents to believe that their child’s feeding is problematic in that it contradicts their perceptions of healthy eating (Kessler et al., 2010). This further indicates the need for adopting a multifactorial approach to feeding problems as considering nutrition in isolation may not capture the perception of the feeding problems from the parents’ perspective. Within clinical samples of children with feeding problems, however, it may be more likely that children are nutritionally compromised, as suggested by diagnostic criteria (American Psychological Society (APA), 2000), and this in itself may constitute a cause for parental concern. This study should be replicated within a clinical sample to establish whether this is the case, thus differing from a non-clinical sample. Finally, the study aimed to further extend previous findings of a relationship between feeding and anxiety by establishing whether parents’ anxiety could predict the correspondence between parents’ reports of feeding problems and children’s intake. Correspondence referred to whether parents’ reports of feeding problems were reflected in the child’s inadequate intake. For example, non-correspondence therefore referred to parents reporting problematic feeding, where their child’s intake was adequate. The third hypothesis was supported by the study’s findings, as anxiety was found to predict whether parents’ reports of feeding problems corresponded with the child’s intake. Specifically, parents whose reports did not correspond with their child’s intake had higher anxiety. To date, little research had considered the role of parents’ anxiety in terms of whether parents’ reports of feeding problems correspond with the child’s intake. Within the current sample, however, very few parents’ reports did not correspond with intake. This is potentially due to the nonclinical population, as it is unlikely that the children’s feeding would be particularly problematic. The current study provides an initial exploration of the relationship between parent report of feeding, children’s intake and parental anxiety. However, although no statistical assumptions were violated by the unequal group size, future research should include a larger non-clinical sample and a clinical sample for comparison, in order to establish whether results from the current study are generalisable across clinical and non-clinical populations. Furthermore, although higher anxiety was found to predict non-correspondence between parents’ reports of feeding problems and children’s intake, the non-correspondence group in this study consisted both of parents whose reports of feeding problems were coupled with adequate intake in their child and of parents whose reports of normal feeding were coupled with low intake; the latter is not supported by the literature and requires further consideration. However, within a clinical sample, this would be expected to occur less frequently, as parents will have reported a feeding problem in their child in order to be seen clinically. Thus, the non-correspondence group would be expected to consist only of parents whose reports of a problem are not reflected in inadequate intake. This again supports the need to investigate this relationship further, with the inclusion of a clinical group.
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A potential confounder in the analysis might be children’s weights. Recent literature has explored parents’ concerns about their children’s weights in relation to children’s intake (BossinkTuna et al., 2009). Weight therefore represents a further factor to consider in future research. The current study had some limitations. First, participants in the current study were selfselected. This may represent a bias in the sample, potentially attracting a higher proportion of parents with concerns or anxiety associated with their child’s feeding. Furthermore, the measure of intake could potentially have been problematic as, although previous studies have used food diaries as measures of intake (Falciglia et al., 2001) and the food diary data were analysed objectively, using CompEAT, the diary itself was completed by the parent and therefore comprised of a subjective element. It was therefore subject to inaccurate reports in terms of amounts, with the potential to underestimate (Hill and Davies, 2001). If parents’ completion of food diaries was inaccurate, the analysis of the child’s intake would also not have represented an accurate objective measure of intake. Furthermore, the current study asked parents to detail their child’s eating on a ‘typical’ day in an attempt to increase response rates by reducing the time burdens upon parents as a result of filling in the diary over a longer period. In order to glean a more accurate and robust indication of children’s intake, future research utilising a food diary method might consider asking parents to complete a minimum of a three-day diary. The food diary method is also subject to social desirability bias as parents may wish to be seen to be providing their child with a balanced diet (Hanson et al., 2005), especially as healthy eating is widely encouraged in schools (Shepherd et al., 2006), from which participants in the current study were recruited. Despite its flaws, this method was deemed to be the most convenient and appropriate method for the current study. A further limitation of the current study is its small sample size and the very small proportion of participants whose children were reported to display problematic feeding behaviour. As a result, current findings could not be meaningfully generalised to the wider population or applied to a sample of children with clinically significant feeding problems. It does, however, provide an initial investigation of parents’ reports of feeding and intake, along with the relationship with parental anxiety, in a non-clinical population. Previous research has not been able to determine causality in the relationship between children’s feeding and parental anxiety (Coulthard and Harris, 2003). Similarly, as correlations were used in the current study, causality was again not established; presenting another limitation of this study. This should therefore be considered in future work. The current research has further evidenced anxiety as a factor associated with parents’ reports of feeding problems, in line with previous research (Hellin and Waller, 1992; Jones and Bryant-Waugh, 2013). This finding, within a non-clinical population, may have implications in terms of the information available to parents regarding their children’s feeding and nutrition, including what constitutes ‘problematic’ eating and what remains within a normal spectrum. Interventions may be necessary to reassure parents that ‘normal’ eating can look different to each individual (Birch, 1999). In conclusion, this study did not replicate previous findings of an association between parents’ reports of feeding problems and children’s intake and therefore highlights the importance of a multifactorial approach to understanding reported child feeding difficulties. Much research has focused on nutritional intake in isolation and this study has suggested that this alone may not be able to adequately define a child’s feeding problem. The current study was able to provide an extension to the literature regarding the role of anxiety in parental reports of feeding problems. In particular, findings that parental anxiety could predict the correspondence between parents’ reports and children’s intake in the current sample raised questions regarding the appropriateness of relying upon nutritional information alone where
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parents have higher levels of anxiety. However, as the full extent and causality of this relationship was not established in the current study, further investigation is necessary in this area. Conflict of interest The authors declared no conflicts of interest. Funding This research received no specific grant from any funding agency in the public, commercial or not-for-profit sectors. References Aldridge VK, Dovey TM, Martin CI and Meyer C (2010) Identifying clinically relevant feeding problems and disorders. Journal of Child Health Care 14(3): 261–270. American Psychiatric Association (APA) (2000) DSM IV-TR: Diagnostic and Statistical Manual Mental Disorders: Text Revision. Washington, DC: American Psychiatric Association. Birch LL (1999) Development of food preferences. Annual Review of Nutrition 19(1): 41–62. Bossink-Tuna HN, L’hoir MP, Beltman M and Boere-Boonekamp MM (2009) Parental perception of weight and weight-related behaviour in 2-to 4-year-old children in the eastern part of the Netherlands. European Journal of Pediatrics 168(3): 333–339. Bjelland I, Dahl AA, Haug TT and Neckelmann D (2002) The validity of the hospital anxiety and depression scale: An updated literature review. Journal of Psychosomatic Research 52(2): 69–77. Chatoor I, Conley C and 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(1): 105–110. Chatoor I and Macaoay M (2008) Feeding development and disorders. In: MM Haith and JB Benson (eds) Encyclopedia of Infant and Early Childhood Development. New York, NY: Academic Press, pp. 524–533. Cockroft JE, Durkin M, Masding C and Cade JE (2005) Fruit and vegetable intakes in a sample of preschool children participating in the ‘Five for All’ project in Bradford. Public Health Nutrition 8(07): 861–869. Cohen J (1988) Statistical Power Analysis for the Behavioral Sciences. New York, NY: Academic Press. Cooke L, Carnell S and Wardle J (2006) Food neophobia and mealtime food consumption in 4–5 year old children. International Journal of Behavioral Nutrition and Physical Activity 3(1): 1–6. Cooke L, Wardle J and Gibson EL (2003) Relationship between parental report of food neophobia and everyday food consumption in 2–6 year old children. Appetite 41(2): 205–206. Coulthard H, Blissett J and Harris G (2004) The relationship between parental eating problems and children’s feeding behavior: A selective review of the literature. Eating Behaviors 5(2): 103–115. Coulthard H and Harris G (2003) Early food refusal: The role of maternal mood. Journal of Reproductive and Infant Psychology 21(4): 335–345. Crawford JR, Henry JD, Crombie C and Taylor EP (2001) Normative data for the HADS from a large nonclinical sample. The British Journal of Clinical Psychology 40(Pt 4): 429–434. Crist W and Napier-Phillips A (2001) Mealtime behaviors of young children: A comparison of normative and clinical data. Journal of Developmental and Behavioral Pediatrics 22(5): 279–286. Department of Health (1991) Dietary reference values for food, energy and nutrients for the United Kingdom. Report on Health and Social Subjects 41: 174–177. Dovey TM, Isherwood E, Aldridge VK and Martin CI (2010) Typology of feeding disorders based on a single assessment system: Formulation of a clinical decision-making model. Infant, Child, and Adolescent Nutrition 2(1): 45–51.
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