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Parent and child mealtime behavior in families of children with cystic fibrosis
P
Parent and child mealtime behavior in families of children with cystic fibrosis
Lori J. Stark, PhD, Elissa Jelalian, PhD, Scott W. Powers, PhD, Mary M. Mulvihill, PhD, Lisa C. Opipari, PhD, Anne Bowen, PhD, Ivan Harwood, MD, Mary Anne Passero, MD, Allan Lapey, MD, Michael Light, MD, and Melbourne F. Hovell, MD, MPH Objectives: We investigated the hypothesis that children with cystic fibrosis (CF) and their parents would show more maladaptive behaviors during dinner than children without CF and their parents. Study design: Children with CF (n = 32) and their parents were compared with 29 children without CF and their parents on the rate and frequency of parent-child behaviors during a typical dinner in the families’ homes by using multivariate analyses of variance. Results: When the rate of behavior, controlling for meal length, was examined, no differences were found between groups. However, parents of children with CF were found to differ from parents of control subjects in the frequency of direct and indirect commands (P<.05), coaxes (P<.01), physical prompts (P<.01), and feeding their child (P<.05). Children with CF were found to engage in more talk, spend more time away from the table, refuse food, and exhibit more noncompliance toward commands to eat than control children (P<.05 for all child variables). When behaviors were examined as a function of meal phase, parents of children with and without CF both showed an increase in commands (P<.01), coaxes (P<.05), feeds (P<.01), and physical prompts (P<.01) in the second half of the meal as compared with the first. Children with CF and the control children showed an increase in behaviors incompatible with eating during the second half of the meal compared with the first (P<.01). When faster eaters were compared with slower eaters, faster eaters consumed a higher percentage of the recommended daily allowance of energy (P<.01) than slower eaters and showed a trend to be at higher weight percentiles for age and sex (P = .08) regardless of group (CF or control). Conclusions: Children with CF and their parents do not differ from children without CF and their parents in the rate of behaviors exhibited or types of strategies used to encourage eating. However, children with CF and their parents engage in these behaviors more frequently. Our data do not support typical parenting behaviors as effective in meeting the CF dietary requirements. Additional support in the form of child behavior management training may be needed to assist parents in meeting their child’s caloric requirements. (J Pediatr 2000;136:195-200) Nutrition is important in the management of many chronic illnesses such as diabetes, phenylketonuria, and cystic fibrosis. CF provides an ideal context
for examining factors that affect dietary adherence because nutritional status is strongly associated with survival,1,2 and mealtime is one of the
From the Departments of Psychiatry and Human Behavior and Pediatrics, Brown University School of Medicine, Providence, Rhode Island; the Division of Psychology, Children’s Hospital Medical Center/University of Cincinnati College of Medicine, Cincinnati, Ohio; the Department of Pediatrics, University of California, San Diego Medical Center; the Department of Pediatrics, Massachusetts General Hospital/Harvard Medical School, Boston, Massachusetts; and the Graduate School of Public Health, State University, San Diego, California. Supported by Grant Z-117 from the National Cystic Fibrosis Foundation (to Lori J. Stark, PhD).
Submitted for publication July 13, 1998; revisions received May 27, 1999, July 28, 1999, and Sept 16, 1999; accepted Sept 21, 1999. Reprint requests: Lori J. Stark, PhD, Children’s Hospital Medical Center, 3333 Burnet Ave, Division of Psychology OSB-4, Cincinnati, OH 45229. Copyright © 2000 by Mosby, Inc. 0022-3476/2000/$12.00 +0 9/21/103361
most frequently cited problems by families of children with CF.3 Despite the importance of diet, it is one of the least complied with components of See related article, p. 188.
ANOVA CF DINE
Univariate analysis of variance Cystic fibrosis Dyadic Interaction Nomenclature for Eating MANOVA Multivariate analysis of variance RDA Recommended daily allowance
treatment in CF,4,5 and understanding of the factors that influence adherence 195
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is limited. Parents of children with CF report that their children engaged in more problematic behaviors (eg, long meals, delay of eating by talking, spitting out food) and that they engage in higher rates of “ineffective” strategies (eg, coaxing, making a second meal) than parents of control subjects.6 Higher rates of problem behaviors were significantly correlated with lower caloric intake in the children with CF.6 Despite parental reports of problematic mealtime behavior, no objective measures of actual mealtime behaviors in families have been made to validate and empirically examine these concerns. Because problem eating is a common concern for parents of young children,7,8 understanding the differences in mealtime behavior between children with CF and their parents, and between children without CF and their parents, would be useful in formulating treatment approaches to dietary adherence. The goal of this study was to investigate whether the rate of occurrence or absolute frequency of mealtime behaviors of children with CF and their parents differed from children without CF and their parents by using objective, direct observation methodology. Behaviors were classified a priori as “ineffective” and “effective” based on the parent training literature9 and studies of children with feeding problems.10,11 Both rate and frequency of behaviors were examined because each contributes different information to our understanding of mealtime dynamics. Parent and child behaviors were also examined by meal half to see whether maladaptive behaviors escalated over the course of the meal. We hypothesized that children with CF and their parents would escalate in the rate and frequency of “ineffective” behaviors across the meal. Because the majority of a meal is consumed in the first 20 minutes and because extended meals have not been found to be productive in terms of the amount of food consumed,12 we examined the characteris196
THE JOURNAL OF PEDIATRICS FEBRUARY 2000 tics of children who finished their meal within 20 minutes. We hypothesized that children who took longer than 20 minutes at the meal would demonstrate a higher rate and frequency of behaviors incompatible with eating.
METHODS Participants The participants in this study were previously described in a study by Stark et al13 and consisted of 32 families of children with CF between the ages of 2 years, 0 months and 5 years, 11 months. Subjects were recruited from 3 CF centers: Rhode Island Hospital, Massachusetts General Hospital, and the University of California, San Diego Medical Center. Inclusion criteria have been described previously.13 Of eligible families, 80% agreed to participate and signed informed consent documents. The mean age for the children was 4 years, 4 months. Forty percent of the children were female and 60% were male. They ranged in weight from below the 5th to 95th percentile weight for age. Twenty-nine families of children without CF, matched to the children with CF in age (within 1 year), gender, socioeconomic status14 (within 2 categories), presence of siblings, and number of parents present at dinner, were recruited as control subjects. The children ranged in age from 2 years, 0 months to 6 years, 1 month with a mean age of 4 years, 2 months. Forty-one percent were female and 59% were male. They ranged in weight from the 30th percentile to the 90th percentile weight for age. Recruitment procedures have previously been described.13
Procedure Videotaped recordings of family dinners were collected during home visits. Home visits were scheduled at the convenience of each family and at their typical dinner time. On the first home visit, the video camera was set up on
arrival, the target child was weighed, and the consent form was completed. Parents were taught to keep a 3-day food diary. On subsequent home visits, the research assistant set up the video camera, briefly reviewed the diet diaries, and left the dining area once the camera was turned on. To assess for reactivity of the recording procedures, parents rated the similarity of each videotaped dinner, as compared with routine dinners in the home, in terms of the target child’s eating behavior and general interactions with the family. Three meals, rated as typical, were used for data analysis. The average number of home visits required to collect 3 representative meals was 3.2 (range, 3 to 6). Once data collection was completed, parents were mailed a check for $20 as compensation for their participation.
Dependent Measures WEIGHT. Weight was measured by means of a SECA portable scale (model 815, SECA, Columbia, Md), which is accurate within 0.2 kg over its entire weighing range (0 to 130 kg). Children were weighed in their street clothes without shoes a minimum of 2 times or until their weight was within 0.2 kg on 2 consecutive weighings. DIET DIARIES. Parents were instructed to monitor their child’s food and liquid intake on 3 separate days by means of a food diary. Parents were provided a Weight Watchers food scale for accurate food measurement. Three-day food diaries were chosen because they are representative of intake over a 7day period.15,16 If a videotaped dinner did not fall within the 3-day diet record, a “dinner only” diet record was kept to capture calories consumed at the filmed dinner. Dinner diaries and 3-day diet diaries were analyzed by means of Nutripractor 4000, a professional microcomputer software system designed for nutrient analysis and diet planning (Practorcare, San Diego,
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THE JOURNAL OF PEDIATRICS VOLUME 136, NUMBER 2 Calif). Data on intake were published previously.13 Caloric data are presented as average calories consumed at the videotaped dinner meal and percentage RDA for energy. These data are correlated with the rate of eating (within 20 minutes; >20 minutes). DYADIC INTERACTION NOMENCLAEATING. The DINE was developed from the literature on failure to thrive17 and parenting,9 as well as theory related to behaviors hypothesized to promote and interfere with eating. The DINE consists of 3 categories of behavior: Parent Behaviors, Child Behaviors, and Child Eating. Parent Behaviors include Direct Command, Indirect Command, Coax, Reinforce, Parent Talk, Physical Prompt, and Feed. Definitions of Direct and Indirect Commands were modified from Alpha and Beta Commands used in the parent training literature9 to be specific to eating. Child Behaviors include Noncompliance to Direct Commands,9 Refuse/Complaints about Food, Requests for Food, Child Talk, and Away from Table/Food. The codes and operational definitions are available upon request. All behaviors except bites were coded on an occurrence/ nonoccurrence basis in 10-second intervals. For bites, number per 10-second interval was recorded. The data on bites have been published13 and are only presented here as the data relate to parent and child behavior during meals. TURE FOR
CODING AND RELIABILITY. Each videotaped dinner was viewed 3 times by an observer. Child Eating was coded during the first viewing, Child Behaviors were coded during the second, and Parent Behaviors were coded during the third. Thirty-three percent of the videotaped dinners (one meal per family) were coded by a second observer. Both the primary and reliability coders were trained on the DINE until they independently achieved 70% reliability on the criterion videotape. Observers
were unaware of each subject’s group status (CF or control). Kappa coefficients were calculated on exact agreement on the occurrence of each behavior within each 10-second interval. Kappa coefficients range from 0 to 1.00, and kappa coefficients of 0.60 are considered acceptable.18 The average kappa coefficient was 0.79 (range, 0.72 to 0.86) for Parent Behaviors, 0.83 (range, 0.79 to 0.92) for Child Behaviors, and 0.97 (range, 0.86 to 0.95) for Child Eating.
Data Analysis Strategy The 3 dinner meals for each subject were averaged for purposes of data analysis. Coded behaviors were aggregated into 3 major categories: Parent Behaviors (direct command, indirect command, reinforcement, physical prompt, coax, and feed); Child Behaviors (talk, away, refuse, request, and noncompliance); and Child Eating (bites and sips). Multivariate analyses of variance were conducted on these 3 major categories. Follow-up univariate analyses of variance were done if MANOVAs were significant. Throughout the results the mean frequency is denoted as “M.”
RESULTS Overall Meal Effects RATE OF PARENT AND CHILD BEHAVIOR (DINE). Because the length of the dinner meal was previously reported to be 6 minutes longer in the CF sample than in the control sample,13 the rate of behavior was calculated (ie, Number of 10-second intervals with occurrence/Total number of 10-second intervals in the meal) for Parent Behaviors, Child Behaviors, and Child Eating. There was a trend toward significance on the overall MANOVA for Parent Behavior (F7,55 = 2.13; P = .06), suggesting a trend for parents of children with CF to engage in a higher rate of mealtime behaviors. The overall MANOVAs for Child Behaviors (F2,60 = 2.27; P > .05) and Child Eating (F5,57
= 0.70; P > .05) were not significant, indicating no differences in the rate of behaviors during the meal. FREQUENCY OF PARENT AND CHILD BEHAVIOR (DINE). Next we examined whether there were group differences in the absolute frequency of behaviors occurring during dinner meals. Absolute frequency is important to examine because the number of times a given behavior occurs may be key in determining the perceived stress of a meal. The MANOVA for frequency of Parent Behaviors was significant (F7,55 = 3.25; P < .01). Follow-up univariate tests indicated that parents of children with CF issued more direct (M = 6.42 vs M = 3.76; F1,61 = 6.15; P < .05) and indirect (M = 7.46 vs M = 4.65; F1,61 = 6.75; P < .05) commands. They also fed their child more frequently (M = 3.90 vs M = 0.90; F1,61 = 5.74; P < .05), provided more physical prompts (M = 4.71 vs M = 2.24; F1,61 = 15.24; P < .01), and gave more coaxes (M = 8.41 vs M = 5.42; F1,61 = 7.52; P < .01). There was no significant difference in the amount of talking or in the amount of reinforcement given to the children. The MANOVA for frequency of Child Behaviors also was significant (F5,57 = 2.92; P < .05). Follow-up univariate tests indicated that children with CF engaged in more behavior incompatible with eating than children without CF. Children with CF talked (M = 66.92 vs M = 50.66; F1,61 = 4.03; P < .05), were away from the table (M = 12.06 vs M = 5.48; F1,61 = 4.64; P < .05), and refused food (M = 3.87 vs 2.73; F1,61 = 4.11; P < .05) more frequently. Children with CF were also more noncompliant with commands to eat (M = 2.09 vs 1.12; F1,61 = 4.17; P < .05). The groups did not differ in the frequency of their requests for food (CF M = 1.96, control M = 1.82). As previously reported,13 no differences were found in frequency of bites. However, children with CF were found to take significantly more sips (M = 7.73 vs M = 4.98; F1,61 = 7.76; P < .05). 197
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Topography of Meals To provide a more refined analysis of parent and child behaviors, the topography of the meals was examined in 2 ways: (1) comparison of the frequency of behavior during the beginning of the meal (first half) versus the end of the meal (second half) and (2) comparison of behaviors of children who completed the meal within 20 minutes versus children who took longer. MEAL HALF ANALYSIS. MANOVA with group membership (CF vs control) and meal half (first vs second) as the independent factors was conducted. PARENT BEHAVIORS. Because of power considerations, only 6 of the 7 parent behavior variables were included in this analysis. Reinforcement was excluded because of low frequency. A significant main effect for meal half was found on the MANOVA for frequency of parent behavior (F6,56 = 6.56; P < .01). ANOVA revealed most parent behaviors occurred more frequently during the second half of the meal than during the first half of the meal regardless of group (CF or control). Parents issued more direct (F1,61 = 10.95; P < .01) and indirect commands (F1,61 = 25.49; P < .01) and did more coaxing (F1,61 = 5.22; P < .05) during the second half of the meal. Parents also engaged in more physical behaviors to encourage eating, including feeding (F1,61 = 14.02; P < .01) and physical prompting (F1,61 = 20.57; P < .01) during the second half of the meal. No group by time interaction was found. CHILD BEHAVIORS. There was also a significant main effect for meal half on the MANOVA for frequency of child behaviors (F5,57 = 15.84; P < .01). Many of the child behaviors hypothesized to be incompatible with eating occurred more frequently during the second half of the meal than during the first half of the meal regardless of group (CF or control). Follow-up ANOVA indicated that children were 198
THE JOURNAL OF PEDIATRICS FEBRUARY 2000 away from the table (F1,61 = 12.65; P < .01), refused food more frequently (F1,61 = 43.29; P < .01), and were more noncompliant with commands to eat (F1,61 = 15.47; P < .01) during the second half of the meal. No differences were found between the first and second halves of the meal on behaviors of child talk or request for food. No group by time interaction was found. CHILD EATING. A significant main effect for meal half was also found for child eating (F2,60 = 18.25; P < .01). Follow-up ANOVAs indicated fewer bites were taken in the second half of the meal (F1,61 = 37.09; P < .01). No differences were found in the number of sips across the meal. No group by meal half interaction was found. CHARACTERISTICS OF “TIMELY EATERS.” Children who completed the meal within 20 minutes (faster eaters) were compared with those who took longer (slower eaters) on the rate of parent and child behaviors. The overall MANOVAs for Parent Behaviors (F7,53 = 2.41; P < .05), Child Behaviors (F5,55 = 4.09; P < .01), and Child Eating (F2,58 = 3.74; P < .05) were all significant for type of eater (slow vs fast). The interaction between type of eater and group status (CF vs control) was not significant for any of the mealtime behaviors. Follow-up tests indicated that parents of faster eaters offered more physical prompts (F1,59 = 8.44; P < .01; M = .04 vs M = .02) and did more feeding (F1,59 = 3.76; P < .06; M = .03 vs M = .01). Faster eaters also had a higher proportion of bites (F1,59 = 7.55; P < .01; M = .41 vs M = .33) and a greater proportion of requests (F1,59 = 12.03; P < .01; M = .02 vs M = .01). Slower and faster eaters were also compared on the frequency of parent and child behaviors. The overall MANOVAs for Parent Behaviors (F7,53 = 3.88; P < .01), Child Behaviors (F5,55 = 5.24; P < .01), and Child Eating (F2,58 = 4.19; P < .05) were all significant for type of eater. The interaction
between group status and type of eater was not significant for any of the mealtime behaviors. Follow-up univariate ANOVAs of Parent Behaviors indicated that parents of faster eaters engaged in fewer direct (F1,59 = 10.38; P < .01; M = 3.42 vs M = 6.81) and indirect commands (F1,59 = 6.14; P < .05; M = 4.62 vs M = 7.33), and did less coaxing (F1,59 = 9.64; P < .01; M = 5.10 vs M = 8.38) and talking (F1,59 = 11.14; P < .01; M = 39.97 vs M = 61.08). Follow-up analyses of Child Behaviors indicated faster eaters were found to engage in less talk (F1,59 = 20.77; P < .01; M = 42.22 vs M = 76.04) and to demonstrate less noncompliance (F1,59 = 9.10; P < .01; M = 0.86 vs M = 2.27). There was a trend for faster eaters to request more food (F1,59 = 3.88; P < .06; M = 2.34 vs M = 1.49). Analysis of Child Eating during meals indicated that faster eaters were found to take fewer bites (F1,59 = 6.29; P < .01; M = 46.72 vs M = 62.00) and fewer sips (F1,59 = 4.39; P < .05; M = 5.13 vs M = 7.22). Finally, faster eaters were compared with slower eaters in terms of percent RDA for energy, weight percentile, and calories from solid food versus liquid. The overall MANOVA for RDA for energy and weight percentile was significant for type of eater (F2,58 = 6.66; P < .01), but not for the interaction between group status and type of eater (F2,58 = 0.82; P>.05). Follow-up univariate ANOVAs indicated that faster eaters were at a higher percent RDA for energy (M = 97.48 vs M = 92.4; F1,59 = 11.70; P < .001. There was a trend for faster eaters to be at a higher weight percentile (M = 61.3 vs M = 49.4), but this difference was not significant (F1,59 = 3.04; P = .08). Children were also compared as to the number of calories consumed from solid foods and combined solid and liquid during dinner. The MANOVA was significant for type of eater (F2,57 = 3.47; P < .05), but not the interaction between group status and type of eater (F2,57 = 1.178; P > .05). Univariate ANOVAs revealed that faster eaters
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THE JOURNAL OF PEDIATRICS VOLUME 136, NUMBER 2 consumed fewer total calories during dinner (F1,58 = 6.29; P < .05) and showed a trend toward taking fewer calories from solid foods (F1,58 = 3.84; P < .06).
DISCUSSION As hypothesized, parents of children with CF were found to engage in a higher frequency of ineffective child management strategies of indirect commands, coaxing, and feeding than parents of children without CF. However, contrary to hypotheses, they were also found to engage in a higher frequency of effective child management strategies, such as direct commands, and a similar frequency of reinforcement of eating. Children with CF in this study were found to engage in a higher frequency of behaviors incompatible with eating such as talking, being away from the table, and refusing food. Children with CF were also found to be more noncompliant in response to a command to eat. However, when parent and child mealtime behaviors were examined as rate, controlling for time, there were no differences between the 2 groups. Thus although parents of children with CF engage in management strategies similar to those of parents of children without CF, they differ in that they keep their child at the dinner table longer. Longer meals then result in an increase in the use of typical parenting strategies, rather than the emergence of atypical parenting strategies. To further examine this possibility, the pattern of parent and child behaviors was examined for the beginning versus the end of the meal. We initially hypothesized that parent and child behavior would escalate in the CF sample across the 2 phases of the meal. However, the results showed that over the course of the meal, children in both groups decreased their frequency of taking bites and increased in the frequency of food refusal, noncompliance, and leaving
the table. During this same period, parents of children with CF and parents of control subjects increased their efforts to get their child to eat by issuing more commands, coaxing, feeding, and prompting their child to eat. This pattern of behavior was similar across parents of children with and without CF. However, because the children with CF took an average of 6 minutes more at the dinner meal,13 these behaviors occurred at almost twice the frequency in families with a child with CF than in the families of the control children. Given previous parent reports of how difficult meals are3 and parent ratings of mealtime behaviors as problematic,6,13 it is likely that the extended meal times lead to increased behavior problems and parent management attempts. This increase in behavior may be associated with stress and frustration for the parents. Because one parental strategy for increasing children’s food consumption appeared to be keeping them at the table longer, the efficacy of this strategy was evaluated by examining the relationship between time spent at dinner and the child’s food consumption at that meal, the average percent RDA for energy, and the children’s weight percentile. We found that children who spent more than 20 minutes at dinner ate more absolute calories at that meal than children who spent less than 20 minutes. However, we also found that these children had a lower overall RDA for energy (92% vs 97% RDA for energy), and there was a trend for them to be at lower weight percentiles (49.35th vs 61.25th percentile). Thus the strategy of longer mealtimes appears to be effective in the short-term (ie, at the dinner meal) but does not appear to be an effective long-term strategy. The children who took longer than 20 minutes did not eat more over the course of a day (ie, lower RDA for energy) and also did not demonstrate any benefit in terms of their weight percentile. Interestingly, there was no group interaction indicating that
longer mealtimes are not an effective means of increasing caloric intake in children either with or without CF. Because these results are correlational, the direction of the relationship is not clear. It may be that children who are underweight elicit more parental concern and attempts to get them to eat. It is also possible that the percent RDA for energy and weight percentile of slower eaters would be lower if they did not remain at the table beyond 20 minutes. However, the cost of this strategy is high in terms of potential increased stress at mealtime and the benefit, if present, is not sufficient to meet the CF RDA of 120% to 150%. Because weight gain in CF is affected by disease severity and malabsorption, it may be that children who ate more slowly had more severe disease or malabsorption and thus were at a lower weight percentile because of these factors and not caloric intake. This study did not assess disease severity or malabsorption; this remains to be assessed in future research. However, factors such as more severe disease or malabsorption typically increase the caloric demand and thus are likely to present even more difficult challenges to parents in meeting the energy requirements than the average child with CF. Finally, the sample size of this study raises questions of whether the findings can be generalized to the population at large. We would argue, however, that the representative nature of the results is enhanced by the recruitment rate (80%) and the geographical diversity (East Coast, West Coast) of the sample. Overall, the results highlight the difficulty of achieving the CF RDA. Typical parenting strategies may not be sufficient to meet this challenge. Indeed, in a behavior analysis model of human behavior, typical mealtime parenting behaviors (commands, coaxing, parent feeding) aimed at getting the child to eat may contribute to poor oral intake over time, because the resultant increase in parental attention occurs in 199
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response to not eating, thereby inadvertently reinforcing this undesired response. In this study interactions were not coded sequentially; therefore, consequences of child bites or lack of bites cannot be examined directly. However, several intervention studies in which parents of children with CF are taught behavioral child management strategies (ie, contingent attention, ignoring, contingent rewards, and shaping) in addition to nutritional information lend support to this hypothesis. In these studies, improved parent management was associated with increased calories, weight, bites per minute, and calories per bite.19-21 The results of this study provide additional data regarding the importance of behavioral and environmental factors in dietary adherence in children with CF and provide a model for examining these factors in the nutritional management of other chronic illnesses. We thank Sijia Tao, Julie Heiber, Meg Vanachtenberg, and Kristen Keating for conducting the filming of families and coding the video tapes.
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protein turnover, and course of pulmonary disease. J Pediatr 1986;109: 788-94. Quittner AL, DiGirolamo AM, Winslow EB. Problems in parenting a child with cystic fibrosis: a contextual analysis. Paper presented at the Florida Conference on Child Health Psychology, Apr 1991; Gainesville, FL. Carter BD, Kronenberger WG, Conradsen E. Marital quality, parenting stress, and compliance in families of children with cystic fibrosis. Paper presented at the Florida Conference on Child Health Psychology, Apr 1993; Gainesville, FL. Gudas LJ, Koocher GP, Wypij D. Perceptions of medical compliance in children and adolescents with cystic fibrosis. Dev Behav Pediatr 1991;12: 236-42. Crist W, McDonnell P, Beck M, Gillespie CT, Barrett P, Mathews J. Behavior at mealtimes and nutritional intake in the young child with cystic fibrosis. Dev Behav Pediatr 1994;15:157-61. Bentovim A. The clinical approach to feeding disorders of childhood. J Psychosom Res 1970;14:267-76. Hertzler AA. Children’s food patterns—a review; I: food preferences and feeding problems. J Am Dietetic Assoc 1983;83:551-4. Forehand RL, McMahon RJ. Helping the noncompliant child. New York: The Guilford Press; 1981. Linscheid TR, Budd KS, Rasnake LK. Pediatric feeding disorders. In: Roberts M, editor. Handbook of pediatric psychology. 2nd ed. New York: The Guilford Press; 1995. p. 501-15. Sanders MR, Patel RK, LeGrice B, Shepherd RW. Children with persistent feeding difficulties: an observational analysis of the feeding interactions of problem and non-problem eaters. Health Psychol 1993;12:64-73. Wolff RP, Lierman CJ. Management
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of behavioral feeding problems in young children. Infants and Young Children 1994;7:14-23. Stark LJ, Jelalian E, Mulvihill MM, Powers SW, Bowen AM, Spieth LE, et al. Eating in preschool children with cystic fibrosis and healthy peers: a behavioral analysis. Pediatrics 1995;95: 210-5. Hollingshead AB. Two factor index of social status. New Haven, CT: Yale University; 1975. Daniels LA. Collection of dietary data from children with cystic fibrosis: some problems and practicalities. Hum Nutr: Appl Nutr 1984;38:110-8. St. Jeor ST, Guthrie HA, Jones MB. Variability in nutrient intake in a 28day period. J Am Dietetic Assoc 1983;83:155-62. Thompson RJ, Palmer S, Linscheid TR. Single-subject design and interaction analysis in the behavioral treatment of a child with a feeding problem. Child Psychiatr Hum Dev 1977;8: 43-53. Hartman DP. Consideration in the choice of interobserver reliability estimates. J Appl Behav Anal 1977;10: 103-16. Stark LJ, Bowen AM, Tyc VL, Evans S, Passero MA. A behavioral approach to increasing calorie consumption in children with cystic fibrosis. J Pediatr Psychol 1990;15:309-26. Stark LJ, Knapp L, Bowen AM, Powers SW, Jelalian E, Evans S, et al. Increasing calorie consumption in children with cystic fibrosis: replication with two year follow-up. J Appl Behav Anal 1993;26:435-50. Stark LJ, Mulvihill MA, Powers SW, Jelalian E, Keating K, Creveling S, et al. Behavioral intervention to improve calorie intake of children with cystic fibrosis: treatment vs wait-list controls. J Pediatr Gastroenterol Nutr 1996;22: 240-53.
Parent and child mealtime behavior in families of children with cystic fibrosis
Lori J. Stark, PhD, Elissa Jelalian, PhD, Scott W. Powers, PhD, Mary M. Mulvihill, PhD, Lisa C. Opipari, PhD, Anne Bowen, PhD, Ivan Harwood, MD, Mary Anne Passero, MD, Allan Lapey, MD, Michael Light, MD, and Melbourne F. Hovell, MD, MPH Objectives: We investigated the hypothesis that children with cystic fibrosis (CF) and their parents would show more maladaptive behaviors during dinner than children without CF and their parents. Study design: Children with CF (n = 32) and their parents were compared with 29 children without CF and their parents on the rate and frequency of parent-child behaviors during a typical dinner in the families’ homes by using multivariate analyses of variance. Results: When the rate of behavior, controlling for meal length, was examined, no differences were found between groups. However, parents of children with CF were found to differ from parents of control subjects in the frequency of direct and indirect commands (P<.05), coaxes (P<.01), physical prompts (P<.01), and feeding their child (P<.05). Children with CF were found to engage in more talk, spend more time away from the table, refuse food, and exhibit more noncompliance toward commands to eat than control children (P<.05 for all child variables). When behaviors were examined as a function of meal phase, parents of children with and without CF both showed an increase in commands (P<.01), coaxes (P<.05), feeds (P<.01), and physical prompts (P<.01) in the second half of the meal as compared with the first. Children with CF and the control children showed an increase in behaviors incompatible with eating during the second half of the meal compared with the first (P<.01). When faster eaters were compared with slower eaters, faster eaters consumed a higher percentage of the recommended daily allowance of energy (P<.01) than slower eaters and showed a trend to be at higher weight percentiles for age and sex (P = .08) regardless of group (CF or control). Conclusions: Children with CF and their parents do not differ from children without CF and their parents in the rate of behaviors exhibited or types of strategies used to encourage eating. However, children with CF and their parents engage in these behaviors more frequently. Our data do not support typical parenting behaviors as effective in meeting the CF dietary requirements. Additional support in the form of child behavior management training may be needed to assist parents in meeting their child’s caloric requirements. (J Pediatr 2000;136:195-200) Nutrition is important in the management of many chronic illnesses such as diabetes, phenylketonuria, and cystic fibrosis. CF provides an ideal context
for examining factors that affect dietary adherence because nutritional status is strongly associated with survival,1,2 and mealtime is one of the
From the Departments of Psychiatry and Human Behavior and Pediatrics, Brown University School of Medicine, Providence, Rhode Island; the Division of Psychology, Children’s Hospital Medical Center/University of Cincinnati College of Medicine, Cincinnati, Ohio; the Department of Pediatrics, University of California, San Diego Medical Center; the Department of Pediatrics, Massachusetts General Hospital/Harvard Medical School, Boston, Massachusetts; and the Graduate School of Public Health, State University, San Diego, California. Supported by Grant Z-117 from the National Cystic Fibrosis Foundation (to Lori J. Stark, PhD).
Submitted for publication July 13, 1998; revisions received May 27, 1999, July 28, 1999, and Sept 16, 1999; accepted Sept 21, 1999. Reprint requests: Lori J. Stark, PhD, Children’s Hospital Medical Center, 3333 Burnet Ave, Division of Psychology OSB-4, Cincinnati, OH 45229. Copyright © 2000 by Mosby, Inc. 0022-3476/2000/$12.00 +0 9/21/103361
most frequently cited problems by families of children with CF.3 Despite the importance of diet, it is one of the least complied with components of See related article, p. 188.
ANOVA CF DINE
Univariate analysis of variance Cystic fibrosis Dyadic Interaction Nomenclature for Eating MANOVA Multivariate analysis of variance RDA Recommended daily allowance
treatment in CF,4,5 and understanding of the factors that influence adherence 195
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is limited. Parents of children with CF report that their children engaged in more problematic behaviors (eg, long meals, delay of eating by talking, spitting out food) and that they engage in higher rates of “ineffective” strategies (eg, coaxing, making a second meal) than parents of control subjects.6 Higher rates of problem behaviors were significantly correlated with lower caloric intake in the children with CF.6 Despite parental reports of problematic mealtime behavior, no objective measures of actual mealtime behaviors in families have been made to validate and empirically examine these concerns. Because problem eating is a common concern for parents of young children,7,8 understanding the differences in mealtime behavior between children with CF and their parents, and between children without CF and their parents, would be useful in formulating treatment approaches to dietary adherence. The goal of this study was to investigate whether the rate of occurrence or absolute frequency of mealtime behaviors of children with CF and their parents differed from children without CF and their parents by using objective, direct observation methodology. Behaviors were classified a priori as “ineffective” and “effective” based on the parent training literature9 and studies of children with feeding problems.10,11 Both rate and frequency of behaviors were examined because each contributes different information to our understanding of mealtime dynamics. Parent and child behaviors were also examined by meal half to see whether maladaptive behaviors escalated over the course of the meal. We hypothesized that children with CF and their parents would escalate in the rate and frequency of “ineffective” behaviors across the meal. Because the majority of a meal is consumed in the first 20 minutes and because extended meals have not been found to be productive in terms of the amount of food consumed,12 we examined the characteris196
THE JOURNAL OF PEDIATRICS FEBRUARY 2000 tics of children who finished their meal within 20 minutes. We hypothesized that children who took longer than 20 minutes at the meal would demonstrate a higher rate and frequency of behaviors incompatible with eating.
METHODS Participants The participants in this study were previously described in a study by Stark et al13 and consisted of 32 families of children with CF between the ages of 2 years, 0 months and 5 years, 11 months. Subjects were recruited from 3 CF centers: Rhode Island Hospital, Massachusetts General Hospital, and the University of California, San Diego Medical Center. Inclusion criteria have been described previously.13 Of eligible families, 80% agreed to participate and signed informed consent documents. The mean age for the children was 4 years, 4 months. Forty percent of the children were female and 60% were male. They ranged in weight from below the 5th to 95th percentile weight for age. Twenty-nine families of children without CF, matched to the children with CF in age (within 1 year), gender, socioeconomic status14 (within 2 categories), presence of siblings, and number of parents present at dinner, were recruited as control subjects. The children ranged in age from 2 years, 0 months to 6 years, 1 month with a mean age of 4 years, 2 months. Forty-one percent were female and 59% were male. They ranged in weight from the 30th percentile to the 90th percentile weight for age. Recruitment procedures have previously been described.13
Procedure Videotaped recordings of family dinners were collected during home visits. Home visits were scheduled at the convenience of each family and at their typical dinner time. On the first home visit, the video camera was set up on
arrival, the target child was weighed, and the consent form was completed. Parents were taught to keep a 3-day food diary. On subsequent home visits, the research assistant set up the video camera, briefly reviewed the diet diaries, and left the dining area once the camera was turned on. To assess for reactivity of the recording procedures, parents rated the similarity of each videotaped dinner, as compared with routine dinners in the home, in terms of the target child’s eating behavior and general interactions with the family. Three meals, rated as typical, were used for data analysis. The average number of home visits required to collect 3 representative meals was 3.2 (range, 3 to 6). Once data collection was completed, parents were mailed a check for $20 as compensation for their participation.
Dependent Measures WEIGHT. Weight was measured by means of a SECA portable scale (model 815, SECA, Columbia, Md), which is accurate within 0.2 kg over its entire weighing range (0 to 130 kg). Children were weighed in their street clothes without shoes a minimum of 2 times or until their weight was within 0.2 kg on 2 consecutive weighings. DIET DIARIES. Parents were instructed to monitor their child’s food and liquid intake on 3 separate days by means of a food diary. Parents were provided a Weight Watchers food scale for accurate food measurement. Three-day food diaries were chosen because they are representative of intake over a 7day period.15,16 If a videotaped dinner did not fall within the 3-day diet record, a “dinner only” diet record was kept to capture calories consumed at the filmed dinner. Dinner diaries and 3-day diet diaries were analyzed by means of Nutripractor 4000, a professional microcomputer software system designed for nutrient analysis and diet planning (Practorcare, San Diego,
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THE JOURNAL OF PEDIATRICS VOLUME 136, NUMBER 2 Calif). Data on intake were published previously.13 Caloric data are presented as average calories consumed at the videotaped dinner meal and percentage RDA for energy. These data are correlated with the rate of eating (within 20 minutes; >20 minutes). DYADIC INTERACTION NOMENCLAEATING. The DINE was developed from the literature on failure to thrive17 and parenting,9 as well as theory related to behaviors hypothesized to promote and interfere with eating. The DINE consists of 3 categories of behavior: Parent Behaviors, Child Behaviors, and Child Eating. Parent Behaviors include Direct Command, Indirect Command, Coax, Reinforce, Parent Talk, Physical Prompt, and Feed. Definitions of Direct and Indirect Commands were modified from Alpha and Beta Commands used in the parent training literature9 to be specific to eating. Child Behaviors include Noncompliance to Direct Commands,9 Refuse/Complaints about Food, Requests for Food, Child Talk, and Away from Table/Food. The codes and operational definitions are available upon request. All behaviors except bites were coded on an occurrence/ nonoccurrence basis in 10-second intervals. For bites, number per 10-second interval was recorded. The data on bites have been published13 and are only presented here as the data relate to parent and child behavior during meals. TURE FOR
CODING AND RELIABILITY. Each videotaped dinner was viewed 3 times by an observer. Child Eating was coded during the first viewing, Child Behaviors were coded during the second, and Parent Behaviors were coded during the third. Thirty-three percent of the videotaped dinners (one meal per family) were coded by a second observer. Both the primary and reliability coders were trained on the DINE until they independently achieved 70% reliability on the criterion videotape. Observers
were unaware of each subject’s group status (CF or control). Kappa coefficients were calculated on exact agreement on the occurrence of each behavior within each 10-second interval. Kappa coefficients range from 0 to 1.00, and kappa coefficients of 0.60 are considered acceptable.18 The average kappa coefficient was 0.79 (range, 0.72 to 0.86) for Parent Behaviors, 0.83 (range, 0.79 to 0.92) for Child Behaviors, and 0.97 (range, 0.86 to 0.95) for Child Eating.
Data Analysis Strategy The 3 dinner meals for each subject were averaged for purposes of data analysis. Coded behaviors were aggregated into 3 major categories: Parent Behaviors (direct command, indirect command, reinforcement, physical prompt, coax, and feed); Child Behaviors (talk, away, refuse, request, and noncompliance); and Child Eating (bites and sips). Multivariate analyses of variance were conducted on these 3 major categories. Follow-up univariate analyses of variance were done if MANOVAs were significant. Throughout the results the mean frequency is denoted as “M.”
RESULTS Overall Meal Effects RATE OF PARENT AND CHILD BEHAVIOR (DINE). Because the length of the dinner meal was previously reported to be 6 minutes longer in the CF sample than in the control sample,13 the rate of behavior was calculated (ie, Number of 10-second intervals with occurrence/Total number of 10-second intervals in the meal) for Parent Behaviors, Child Behaviors, and Child Eating. There was a trend toward significance on the overall MANOVA for Parent Behavior (F7,55 = 2.13; P = .06), suggesting a trend for parents of children with CF to engage in a higher rate of mealtime behaviors. The overall MANOVAs for Child Behaviors (F2,60 = 2.27; P > .05) and Child Eating (F5,57
= 0.70; P > .05) were not significant, indicating no differences in the rate of behaviors during the meal. FREQUENCY OF PARENT AND CHILD BEHAVIOR (DINE). Next we examined whether there were group differences in the absolute frequency of behaviors occurring during dinner meals. Absolute frequency is important to examine because the number of times a given behavior occurs may be key in determining the perceived stress of a meal. The MANOVA for frequency of Parent Behaviors was significant (F7,55 = 3.25; P < .01). Follow-up univariate tests indicated that parents of children with CF issued more direct (M = 6.42 vs M = 3.76; F1,61 = 6.15; P < .05) and indirect (M = 7.46 vs M = 4.65; F1,61 = 6.75; P < .05) commands. They also fed their child more frequently (M = 3.90 vs M = 0.90; F1,61 = 5.74; P < .05), provided more physical prompts (M = 4.71 vs M = 2.24; F1,61 = 15.24; P < .01), and gave more coaxes (M = 8.41 vs M = 5.42; F1,61 = 7.52; P < .01). There was no significant difference in the amount of talking or in the amount of reinforcement given to the children. The MANOVA for frequency of Child Behaviors also was significant (F5,57 = 2.92; P < .05). Follow-up univariate tests indicated that children with CF engaged in more behavior incompatible with eating than children without CF. Children with CF talked (M = 66.92 vs M = 50.66; F1,61 = 4.03; P < .05), were away from the table (M = 12.06 vs M = 5.48; F1,61 = 4.64; P < .05), and refused food (M = 3.87 vs 2.73; F1,61 = 4.11; P < .05) more frequently. Children with CF were also more noncompliant with commands to eat (M = 2.09 vs 1.12; F1,61 = 4.17; P < .05). The groups did not differ in the frequency of their requests for food (CF M = 1.96, control M = 1.82). As previously reported,13 no differences were found in frequency of bites. However, children with CF were found to take significantly more sips (M = 7.73 vs M = 4.98; F1,61 = 7.76; P < .05). 197
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Topography of Meals To provide a more refined analysis of parent and child behaviors, the topography of the meals was examined in 2 ways: (1) comparison of the frequency of behavior during the beginning of the meal (first half) versus the end of the meal (second half) and (2) comparison of behaviors of children who completed the meal within 20 minutes versus children who took longer. MEAL HALF ANALYSIS. MANOVA with group membership (CF vs control) and meal half (first vs second) as the independent factors was conducted. PARENT BEHAVIORS. Because of power considerations, only 6 of the 7 parent behavior variables were included in this analysis. Reinforcement was excluded because of low frequency. A significant main effect for meal half was found on the MANOVA for frequency of parent behavior (F6,56 = 6.56; P < .01). ANOVA revealed most parent behaviors occurred more frequently during the second half of the meal than during the first half of the meal regardless of group (CF or control). Parents issued more direct (F1,61 = 10.95; P < .01) and indirect commands (F1,61 = 25.49; P < .01) and did more coaxing (F1,61 = 5.22; P < .05) during the second half of the meal. Parents also engaged in more physical behaviors to encourage eating, including feeding (F1,61 = 14.02; P < .01) and physical prompting (F1,61 = 20.57; P < .01) during the second half of the meal. No group by time interaction was found. CHILD BEHAVIORS. There was also a significant main effect for meal half on the MANOVA for frequency of child behaviors (F5,57 = 15.84; P < .01). Many of the child behaviors hypothesized to be incompatible with eating occurred more frequently during the second half of the meal than during the first half of the meal regardless of group (CF or control). Follow-up ANOVA indicated that children were 198
THE JOURNAL OF PEDIATRICS FEBRUARY 2000 away from the table (F1,61 = 12.65; P < .01), refused food more frequently (F1,61 = 43.29; P < .01), and were more noncompliant with commands to eat (F1,61 = 15.47; P < .01) during the second half of the meal. No differences were found between the first and second halves of the meal on behaviors of child talk or request for food. No group by time interaction was found. CHILD EATING. A significant main effect for meal half was also found for child eating (F2,60 = 18.25; P < .01). Follow-up ANOVAs indicated fewer bites were taken in the second half of the meal (F1,61 = 37.09; P < .01). No differences were found in the number of sips across the meal. No group by meal half interaction was found. CHARACTERISTICS OF “TIMELY EATERS.” Children who completed the meal within 20 minutes (faster eaters) were compared with those who took longer (slower eaters) on the rate of parent and child behaviors. The overall MANOVAs for Parent Behaviors (F7,53 = 2.41; P < .05), Child Behaviors (F5,55 = 4.09; P < .01), and Child Eating (F2,58 = 3.74; P < .05) were all significant for type of eater (slow vs fast). The interaction between type of eater and group status (CF vs control) was not significant for any of the mealtime behaviors. Follow-up tests indicated that parents of faster eaters offered more physical prompts (F1,59 = 8.44; P < .01; M = .04 vs M = .02) and did more feeding (F1,59 = 3.76; P < .06; M = .03 vs M = .01). Faster eaters also had a higher proportion of bites (F1,59 = 7.55; P < .01; M = .41 vs M = .33) and a greater proportion of requests (F1,59 = 12.03; P < .01; M = .02 vs M = .01). Slower and faster eaters were also compared on the frequency of parent and child behaviors. The overall MANOVAs for Parent Behaviors (F7,53 = 3.88; P < .01), Child Behaviors (F5,55 = 5.24; P < .01), and Child Eating (F2,58 = 4.19; P < .05) were all significant for type of eater. The interaction
between group status and type of eater was not significant for any of the mealtime behaviors. Follow-up univariate ANOVAs of Parent Behaviors indicated that parents of faster eaters engaged in fewer direct (F1,59 = 10.38; P < .01; M = 3.42 vs M = 6.81) and indirect commands (F1,59 = 6.14; P < .05; M = 4.62 vs M = 7.33), and did less coaxing (F1,59 = 9.64; P < .01; M = 5.10 vs M = 8.38) and talking (F1,59 = 11.14; P < .01; M = 39.97 vs M = 61.08). Follow-up analyses of Child Behaviors indicated faster eaters were found to engage in less talk (F1,59 = 20.77; P < .01; M = 42.22 vs M = 76.04) and to demonstrate less noncompliance (F1,59 = 9.10; P < .01; M = 0.86 vs M = 2.27). There was a trend for faster eaters to request more food (F1,59 = 3.88; P < .06; M = 2.34 vs M = 1.49). Analysis of Child Eating during meals indicated that faster eaters were found to take fewer bites (F1,59 = 6.29; P < .01; M = 46.72 vs M = 62.00) and fewer sips (F1,59 = 4.39; P < .05; M = 5.13 vs M = 7.22). Finally, faster eaters were compared with slower eaters in terms of percent RDA for energy, weight percentile, and calories from solid food versus liquid. The overall MANOVA for RDA for energy and weight percentile was significant for type of eater (F2,58 = 6.66; P < .01), but not for the interaction between group status and type of eater (F2,58 = 0.82; P>.05). Follow-up univariate ANOVAs indicated that faster eaters were at a higher percent RDA for energy (M = 97.48 vs M = 92.4; F1,59 = 11.70; P < .001. There was a trend for faster eaters to be at a higher weight percentile (M = 61.3 vs M = 49.4), but this difference was not significant (F1,59 = 3.04; P = .08). Children were also compared as to the number of calories consumed from solid foods and combined solid and liquid during dinner. The MANOVA was significant for type of eater (F2,57 = 3.47; P < .05), but not the interaction between group status and type of eater (F2,57 = 1.178; P > .05). Univariate ANOVAs revealed that faster eaters
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THE JOURNAL OF PEDIATRICS VOLUME 136, NUMBER 2 consumed fewer total calories during dinner (F1,58 = 6.29; P < .05) and showed a trend toward taking fewer calories from solid foods (F1,58 = 3.84; P < .06).
DISCUSSION As hypothesized, parents of children with CF were found to engage in a higher frequency of ineffective child management strategies of indirect commands, coaxing, and feeding than parents of children without CF. However, contrary to hypotheses, they were also found to engage in a higher frequency of effective child management strategies, such as direct commands, and a similar frequency of reinforcement of eating. Children with CF in this study were found to engage in a higher frequency of behaviors incompatible with eating such as talking, being away from the table, and refusing food. Children with CF were also found to be more noncompliant in response to a command to eat. However, when parent and child mealtime behaviors were examined as rate, controlling for time, there were no differences between the 2 groups. Thus although parents of children with CF engage in management strategies similar to those of parents of children without CF, they differ in that they keep their child at the dinner table longer. Longer meals then result in an increase in the use of typical parenting strategies, rather than the emergence of atypical parenting strategies. To further examine this possibility, the pattern of parent and child behaviors was examined for the beginning versus the end of the meal. We initially hypothesized that parent and child behavior would escalate in the CF sample across the 2 phases of the meal. However, the results showed that over the course of the meal, children in both groups decreased their frequency of taking bites and increased in the frequency of food refusal, noncompliance, and leaving
the table. During this same period, parents of children with CF and parents of control subjects increased their efforts to get their child to eat by issuing more commands, coaxing, feeding, and prompting their child to eat. This pattern of behavior was similar across parents of children with and without CF. However, because the children with CF took an average of 6 minutes more at the dinner meal,13 these behaviors occurred at almost twice the frequency in families with a child with CF than in the families of the control children. Given previous parent reports of how difficult meals are3 and parent ratings of mealtime behaviors as problematic,6,13 it is likely that the extended meal times lead to increased behavior problems and parent management attempts. This increase in behavior may be associated with stress and frustration for the parents. Because one parental strategy for increasing children’s food consumption appeared to be keeping them at the table longer, the efficacy of this strategy was evaluated by examining the relationship between time spent at dinner and the child’s food consumption at that meal, the average percent RDA for energy, and the children’s weight percentile. We found that children who spent more than 20 minutes at dinner ate more absolute calories at that meal than children who spent less than 20 minutes. However, we also found that these children had a lower overall RDA for energy (92% vs 97% RDA for energy), and there was a trend for them to be at lower weight percentiles (49.35th vs 61.25th percentile). Thus the strategy of longer mealtimes appears to be effective in the short-term (ie, at the dinner meal) but does not appear to be an effective long-term strategy. The children who took longer than 20 minutes did not eat more over the course of a day (ie, lower RDA for energy) and also did not demonstrate any benefit in terms of their weight percentile. Interestingly, there was no group interaction indicating that
longer mealtimes are not an effective means of increasing caloric intake in children either with or without CF. Because these results are correlational, the direction of the relationship is not clear. It may be that children who are underweight elicit more parental concern and attempts to get them to eat. It is also possible that the percent RDA for energy and weight percentile of slower eaters would be lower if they did not remain at the table beyond 20 minutes. However, the cost of this strategy is high in terms of potential increased stress at mealtime and the benefit, if present, is not sufficient to meet the CF RDA of 120% to 150%. Because weight gain in CF is affected by disease severity and malabsorption, it may be that children who ate more slowly had more severe disease or malabsorption and thus were at a lower weight percentile because of these factors and not caloric intake. This study did not assess disease severity or malabsorption; this remains to be assessed in future research. However, factors such as more severe disease or malabsorption typically increase the caloric demand and thus are likely to present even more difficult challenges to parents in meeting the energy requirements than the average child with CF. Finally, the sample size of this study raises questions of whether the findings can be generalized to the population at large. We would argue, however, that the representative nature of the results is enhanced by the recruitment rate (80%) and the geographical diversity (East Coast, West Coast) of the sample. Overall, the results highlight the difficulty of achieving the CF RDA. Typical parenting strategies may not be sufficient to meet this challenge. Indeed, in a behavior analysis model of human behavior, typical mealtime parenting behaviors (commands, coaxing, parent feeding) aimed at getting the child to eat may contribute to poor oral intake over time, because the resultant increase in parental attention occurs in 199
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response to not eating, thereby inadvertently reinforcing this undesired response. In this study interactions were not coded sequentially; therefore, consequences of child bites or lack of bites cannot be examined directly. However, several intervention studies in which parents of children with CF are taught behavioral child management strategies (ie, contingent attention, ignoring, contingent rewards, and shaping) in addition to nutritional information lend support to this hypothesis. In these studies, improved parent management was associated with increased calories, weight, bites per minute, and calories per bite.19-21 The results of this study provide additional data regarding the importance of behavioral and environmental factors in dietary adherence in children with CF and provide a model for examining these factors in the nutritional management of other chronic illnesses. We thank Sijia Tao, Julie Heiber, Meg Vanachtenberg, and Kristen Keating for conducting the filming of families and coding the video tapes.
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