Parent-child mealtime interactions associated with toddlers' refusals of novel and familiar foods

PHB-11713; No of Pages 8 Physiology & Behavior xxx (2017) xxx–xxx

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Parent-child mealtime interactions associated with toddlers' refusals of novel and familiar foods Lisa R. Fries ⁎, Nathalie Martin, Klazine van der Horst a

Nestlé Research Center, Lausanne, Switzerland

a r t i c l e

i n f o

Article history: Received 1 December 2016 Received in revised form 17 February 2017 Accepted 2 March 2017 Available online xxxx Keywords: Toddler Feeding practices Behavioral observation Picky eating Food refusals

a b s t r a c t Parents' feeding practices have been associated with children's dietary quality and food acceptance, but previous studies have largely relied exclusively on questionnaires to assess both parent and child behavior. The current study explored the relationships between parents' reported and observed feeding practices and toddlers' food refusals. Sixty families with toddlers (12–36 months-old) video recorded their children's dinners at home as well as a separate meal in which they offered the child a novel fruit or vegetable. Parents completed questionnaires about their feeding practices and children's picky eating and food neophobia. Videos were coded for parents' observed feeding practices at mealtimes and children's food refusals. Parents' feeding practices and children's food refusals were compared in families with children reported to be more picky and less picky eaters. The relationships between reported and observed feeding practices with observed food refusals were also assessed. It was hypothesized that parents' use of controlling and coercive prompts to eat would be associated with children's food refusals. Parent-reported picky eating was not associated with an increase in children's total food refusals, although reported neophobia was associated with more uses of crying, pushing food away, or verbally refusing a new food. More prompts to eat of any kind were associated with more food refusals. In regression models, more observed coercive-controlling prompts used by parents were associated with more food refusals by children. Parents of pickier eaters tended to use a lower proportion of autonomy-supportive prompts to eat, and these families also showed a stronger association between the use of controlling prompts and food refusals. These families may benefit the most from interventions aiming to reduce the use of controlling practices. Models using observed feeding practices were more strongly associated with children's food refusals than were parents' reported feeding practices. This highlights the importance of behavioral observation in this field. © 2017 Published by Elsevier Inc.

1. Introduction Many parents report that their young children are picky eaters [6,32, 43]. Although there's no formal definition of picky eating [13,43], it is generally described as the rejection of foods, which could include both new foods (neophobia) or familiar ones, and many definitions include an element of a limited dietary variety. Generally, it is believed that food neophobia and picky eating peak in early childhood, around ages 2–6, and decline with age [7,13]. Although many children go through a picky eating phase, neophobia or pickiness can make it challenging for parents of toddlers to introduce new foods into a child's diet. Picky eating or food fussiness are typically assessed through questionnaires, relying on the parents' assessment of the child's behavior, which may nor may not reflect children's actual behavior or diet [31]. ⁎ Corresponding author at: Case postale 44, 1000 Lausanne, Switzerland. E-mail address: [email protected] (L.R. Fries).

Depending on the types of questions or analyses used (from single questions (e.g., [8]) to complex latent profiling approaches [12,44]) or the cutoff points selected to identify children as belonging in the picky group [7,18,20], results can lead to substantially different categorizations of children. Some studies are starting to move towards more objective ways of discussing picky eating, such as by focusing on more concrete behaviors, like food refusals, as an outcome, rather than the imprecisely defined “picky eating” [30]. To date, there are very few studies that have explored picky eating through observing child behaviors, such as the acceptance or intake of foods [5,52]. One such behavioral observation study [5] found that 2–4 year-old picky eaters were more likely to be disappointed with the food served, inspect the food, request a different food, or be unwilling to try a food item than were non-picky eaters served the same meals. It is important to note, however, that in that study, the parents both identified their children as picky eaters and evaluated the children's mealtime behavior, thus it is possible that some parents were more likely to perceive behaviors as reflecting

http://dx.doi.org/10.1016/j.physbeh.2017.03.001 0031-9384/© 2017 Published by Elsevier Inc.

Please cite this article as: L.R. Fries, et al., Parent-child mealtime interactions associated with toddlers' refusals of novel and familiar foods, Physiol Behav (2017), http://dx.doi.org/10.1016/j.physbeh.2017.03.001

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L.R. Fries et al. / Physiology & Behavior xxx (2017) xxx–xxx

pickiness, especially for behaviors that require subjective judgment (e.g., if the child looks disappointed). Objective evaluation in observational studies is therefore necessary to identify if these behaviors are more likely to occur in picky eating children or as a result of parent perception. Picky eating can be influenced by environmental factors [42], such as parents' feeding practices or the home food environment [22]. Feeding practices are specific behaviors that parents use to influence what, when, or how much a child eats, such as modeling eating a food, or restricting a child's intake, and many practices have been shown to be associated with children's weight status, diet, and food acceptance [3, 4,41]. Although much of the existing literature on feeding practices and picky eating is based on questionnaire measures (e.g., [29,37,49]), a few studies have explored the associations between feeding practices and food acceptance either through behavioral observation [15,36] or through experimental methods (e.g., [10,16,19,25]). These studies have found that practices such as using pressure to eat [19] or other foods as rewards [15] can decrease children's food acceptance, whereas modeling [1,15,23] or using non-food rewards [10,25] can improve children's willingness to try a food and intake. Although much of the existing literature on feeding practices relies on parent report, these do not necessarily correspond to observed feeding practices (for a review, see: [2]). Therefore, in the current study, food fussiness was measured both through a questionnaire and through behavioral observation. Observations of parent feeding practices and children's food refusals were conducted in two situations: at a typical dinner at home at which the children ate familiar foods, and at a separate meal at which parents were asked to introduce a new fruit or vegetable. We aimed to explore whether different types of prompts to eat and other feeding practices were used differentially by parents of picky and nonpicky eaters, and which practices were most strongly associated with children's observed food refusals. We also compared whether reportedor observed feeding practices better predicted children's food refusals. The current study allowed us to directly observe the feeding practices used by parents at mealtimes as well as the children's eating behaviors, giving us a more in-depth look at how parents act in specific situations and how the children react to various parenting techniques. Based on the existing literature on feeding practices, we hypothesized that more controlling feeding practices would be associated with more observed food refusals. We also expected that parents' observed behaviors would be more strongly associated with children's food refusals than would responses on a feeding practice questionnaire.

Table 1 Participant characteristics. Number of families Mothers Fathers Mean child age in months (SD) Child sex Female Male Race African American Caucasian Multiracial/other Native American Maternal education High school or trade school Some college College grad Some post-grad or more Household income $30,000–49,999 $50,000–79,999 $80,000–99,999 $100,000 or more Average number of children in the family

60 58 2 24.7 (6.8) 29 31 3 49 7 1 4 16 27 13 19 24 7 10 2

2. Methods

occasions over the course of two full days (Monday and Thursday). Families uploaded the videos to a password-protected server at the end of the day. After the practice day of recording (Monday), the videos were reviewed by the research staff and families were given feedback about how to reposition the cameras to improve video or sound quality for optimal recording. The behaviors from the dinner occasion on the second day (Thursday) were coded using the coding scheme described below. One day during the following week, the families were asked to record an additional meal in which they were asked to feed their child a new fruit or vegetable that he/she had never tasted before. As children varied in their previous food experience, parents were free to choose any fruit or vegetable that was new to the child (approximately half chose fruits, half vegetables). By recording both a typical dinner and an occasion when a novel food was being served, we were able to collect naturalistic and objective measures of parents' uses of prompts to eat and children's eating behavior in these two different situations, with the new food situation being hypothesized to be specifically relevant for measuring food neophobia. The following week, parents were asked to complete some questionnaires about feeding practices and children's eating behaviors. Families were compensated for their participation.

2.1. Participants

2.3. Measures

Seventy-five participants were recruited for this study through a recruitment agency, using a database of families with children. Of these, 60 had complete questionnaire data and coded videos and were included for analysis. All families who were recruited lived in the United States, had at least one toddler between the ages of 12–36 months, had one legal guardian over the age of 21 who was a stay-at-home caregiver for the child, had an annual household income over $30,000, and spoke only English in the home. Participant characteristics are presented in Table 1. The children had a mean age of 24.7 months. The stay-athome parents who completed the questionnaires were predominantly mothers, but two were fathers. Families were explained the research procedure by phone and received and signed informed consent forms electronically. This protocol and the associated consent forms were approved by the Copernicus Group IRB (NES1-12-166).

2.3.1. Feeding practices questionnaires The items of the Caregivers Feeding Styles Questionnaire (CFSQ; [27]) were used as measures of parents' reported feeding practices. The questionnaire consists of 19 items which ask parents to indicate how often they use various parenting techniques to encourage children to eat more on a 5-point Likert scale from “never” to “always”. An additional selection of items were selected from other questionnaires to mirror items on the observational coding scheme (described below) so that similar parent-reported parenting practices could be used in the analyses as those observed on the videos. Questions were extracted from the following questionnaires: Comprehensive Feeding Practices Questionnaire (CFPQ; [35]), Family Food Behavior Survey [33], Control in Parent Feeding Practices [34], and Feeding Your Child [39]. Two additional questions were developed and added to address serving additional helpings and whether the child was able to influence the portion size of his food.

2.2. Procedure Two digital video cameras were sent to each family and they were instructed to video record each of their toddler's eating and drinking

2.3.2. Child's picky eating behaviors The food fussiness subscale of the Children's Eating Behaviour Questionnaire (CEBQ; [50]) was used as a measure of picky eating. This scale

Please cite this article as: L.R. Fries, et al., Parent-child mealtime interactions associated with toddlers' refusals of novel and familiar foods, Physiol Behav (2017), http://dx.doi.org/10.1016/j.physbeh.2017.03.001

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contains 6 items (e.g., “my child decides that s/he doesn't like food, even without tasting it”), rated on a 5-point Likert scale from “Never” to “Always”. Two items were reverse-scored (e.g., “My child enjoys tasting new foods”). These items are averaged to create a “food fussiness” score. The Child Food Neophobia Scale (CFNS) was also used to assess food neophobia, or fear of new foods, more specifically. A 6-item version of this scale [9,11] was developed from the original 10-item questionnaire [38], with two reverse-scored items. In the current sample, these scales showed high reliability (Cronbach's alpha: CEBQ FF: 0.91, CFNS: 0.92).

several other parental feeding practices, environmental factors, and several types of child food refusals were coded, as described in Table 2. Four coders were trained through in-person and telephone training sessions and practiced coding using videos from an unpublished pilot study. The coders entered a code and timestamp for each behavior recorded. When completed, the coding sheets were imported into Noldus Observer software (Noldus Information Technology, Wageningen, The Netherlands) to be compiled for analysis. In order to test reliability, 25% of the videos were separately coded by two coders. Reliability analyses were conducted using the Observer software, showing an 86% agreement between coders (κ = 0.850, p b 0.001).

2.3.3. Observational coding An observational coding scheme was developed incorporating elements adapted from previously established coding schemes [26,36], with a focus on techniques used by parents to encourage children to eat more, and the children's eating behavior: consumption and refusals of food. The behaviors included in this coding scheme are described in Table 2. In the current study, prompts to eat were clustered into two categories, following the classification system of Vaughn et al. [48]. Autonomy-supportive prompts (ASP) are parental prompts to eat that allow the child some autonomy in deciding whether or not to eat the food. These included neutral prompts to eat, reasoning, and modeling. Coercive and controlling prompts (CCP) are those in which the parent prompts the child to eat in a way which is more difficult for the child to refuse, due to coercive methods (e.g., rewards) or use of parental authority. These included the use of pressure, food or non-food rewards, or asking the child to finish his food. In addition to the prompts to eat,

2.4. Analyses Repeated-measures t-tests, controlling for length of video, were conducted to compare the frequency of use of various feeding practices in the typical meal (dinner) and new food situation. To compare parents' reports of children's picky eating to observed food refusals, we divided the children using a median split for food fussiness (CEBQ; median: 11; range: 1–22) and compared the “more picky” to “less picky” groups for number and type of food refusals observed during the dinner meal and the new food occasion using between-subjects t-tests. This analysis was repeated using a median split for food neophobia (median: − 2; range: −12 to 12) for the novel food situation. Correlations were conducted between types of prompt to eat and food refusals. Strength of correlations were compared between the picky and less-picky group using a Fisher r-to-z transformation followed by a z-test. Regression analyses were carried out using both parents' observed and reported

Table 2 Examples of the different types of prompts to eat and definitions of other feeding practices that were coded. Prompt type

Subtype

Examples

Autonomy-supportive prompts (ASP)

Neutral Modeling Reasoning

Coercive-controlling prompts (CCP)

Food reward Non-food reward

“Try your hot dog”, “Eat your peas” (neutral or positive tone of voice) [Dad takes a bite of carrot] “Mmmmm” “If you drink your milk, it will make you strong”, “Prunes are like big raisins, so you might like them” “If you eat your broccoli, you can have ice cream” “If you eat your pasta, you can watch TV after dinner”, “If you try the cauliflower, I′ll sing the song again” “Finish your potatoes”, “You only have a few bites left, then you can go” “Just eat your sandwich!” (harsh tone), “If you won't eat, I′m taking away the iPad”

Finish Pressure (including food threat, non-food threat) Definition Other feeding practices Eating together Arranginga Interference Help Allow child to choose portion sizea Change foods Serving food

Choice Criticism Praise Instruction Hurry Restriction Environmental factors Television Child's food refusals Food refusals a

This set of variables were coded if another family member was observed eating during the child's mealtime. Arranging the food to make it more appealing or fun to eat. Parent verbally or physically stops child from doing something. Helping the child to eat, such as by guiding the spoon, moving plate closer, cutting up food. If parent allows child to give input into the quantity of food being served. Parent offers the child another option if child reject initial food offered (e.g., “You don't want hot dogs today? How about spaghetti?”). Three different ways of serving more food were coded:

1. Offer: if parents offered a food to the child (verbally or non-verbally) and wait for child to accept or refuse before serving; 2. Give: if parents serve foods to child without asking if child wants it; 3. Allow: if parent allows child to take food himself or provides it after child request. Allowing child to choose among foods offered. Criticizing child in general or his eating behavior. Praising the child in general or his eating behavior. The parent gives instruction on how to perform an action, including which utensil to use, reminders to perform an action (“chew it up”, “unwrap it”), giving advice (“open your mouth wide!”), correcting (“Sit up straight”, “say ‘please’) and safety warnings (“be careful – it's hot”). Parent tries to encourage child to eat faster or within a certain amount of time. Parent restricts how much food or the amount of a particular food that the child eats. A television or other screen (e.g., Ipad) is on during the meal. Several types of food refusals were coded: turning head away or leaning away from food, pushing food away, crying, spitting food out, closing/covering mouth, ignoring the food offered, or refusing verbally.

This behavior was not observed in the current study and was not included in further analyses.

Please cite this article as: L.R. Fries, et al., Parent-child mealtime interactions associated with toddlers' refusals of novel and familiar foods, Physiol Behav (2017), http://dx.doi.org/10.1016/j.physbeh.2017.03.001

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at both dinner (ASP: r = 0.48; CCP: r = 0.48), and for a new food situation (ASP: r = 0.61; CCP: r = 0.72, all p b 0.01). However, as the rate of using ASP and CCP prompts were also highly correlated (dinner r = 0.62, new food r = 0.62, both p b 0.01), the ratio of ASP prompts to total prompts was used to assess association with the relative frequency of this prompting style. A higher proportion of ASP prompts was found to be associated with fewer food refusals in the new food situation (r = −0.43, p b 0.01), and although the correlation was also in the negative direction for the dinner meal (r = −0.20), this association did not reach significance. Children were divided by median split into those higher on the food fussiness subscale (“more picky”; score of 11 or more; n = 29) and those with lower score (“less picky”; n = 31). Parents of the more picky group used a lower proportion of autonomy-supportive prompts at dinner (70 vs. 82%; p b 0.05; Table 3). There was no difference in meal duration between more picky and less picky eaters (data not shown). When the associations between type of prompt to eat (ASP and CCP) and observed refusals were repeated separately for pickyand less-picky eaters (Table 5), it was found that the positive association between the use of CCP and food refusals was significantly stronger in the picky eating group than in the less-picky group.

feeding practices (separately) as predictors of total observed food refusals. Regression analyses were controlled for the length of the video. 3. Results Parents used more autonomy-supportive prompts in the new food situation than at dinner, both in the absolute (mean 21 vs. 16; p b 0.05) and in proportion to the total prompts used (84% vs. 78%, p b 0.05; Table 3). This difference was even stronger when the analysis was adjusted for the length of the video (p b 0.001), as the new food situation (mean 14.8 min) was a significantly shorter eating occasion than the dinner meal (23.4 min; p b 0.001). Children also made more than twice as many food refusals per minute during the new food occasion (mean 1.13) than during a typical dinner (mean 0.45; p b 0.001). Parents were less likely to eat with their children during the new food situation than during dinner, and also showed a trend for criticizing the child's eating less. When length of video was controlled for, no other behaviors were significantly more or less common across these two eating occasions. 3.1. Comparison between reported fussy eating and observed food refusals When children were divided by median split for their food fussiness score, there were no significant differences in the number of observed food refusals (Table 4). Similarly, when children were divided by their food neophobia scores, there were no differences in observed refusals in the new food situation. This may be due to high within-group variability in the number of refusals. When groups were compared by type of refusal, having a higher score on reported picky eating showed a trend for more crying refusals at dinner (p = 0.10) and when trying a new food (p = 0.09). Children with higher neophobia scores were significantly more likely to use crying refusals in the new food situation (p b 0.05); they were also more likely to cover their mouth (p b 0.05) to refuse new foods.

3.3. Feeding practices that were associated with observed food refusals Using a stepwise regression model, we tested which observed feeding practices best predicted observed food refusals at dinner after controlling for the length of the video (Table 6). The only variable found to be significant in the final model (r2 = 0.389) was the number of CCP (β = 0.543; p b 0.001); other feeding practices were not found to be significant predictors. In the new food situation (r2 = 0.752), CCP were again associated with greater food refusals (β = 0.791; p b 0.001), but three other feeding practices were associated with a lower number of food refusals: verbally offering additional servings to the child (rather than simply giving them; β = −0.163; p b 0.05), praising the child (β = −0.240; p b 0.01), and restricting the child's intake (β = −0.155; p b 0.05). We conducted similar stepwise regressions to test whether parents' reported feeding practices from the questionnaires were associated with observed food refusals during either the dinner meal or when

3.2. Relationship between prompts to eat and observed food refusals More prompts to eat of both the autonomy-supportive (ASP) and coercive-controlling (CCP) types were associated with more food refusals Table 3 Mean number of times different types of prompts and other feeding practices were used (SD). Total sample

Dinner

New food

Dinner

New foods

p-Valuea

Picky eaters

Non-picky

Picky eaters

Non picky

Parent behaviors Autonomy-supportive prompts (ASP) Coercive-controlling prompts (CCP) Proportion ASP prompts of total prompts Mother eats with child Father eats with child Interference Help Change foods Serving foods (give) Choice Criticism Praise Instruction Hurry Restriction

15.9 (13.3) 4.9 (8.1) 78.2% 66% 40% 7.9 (12.2) 8.1 (9.3) 0.02 (0.13) 5.7 (3.4) 0.14 (0.48) 1.4 (3.2) 3.5 (4.0) 14.1 (18.0) 0.24 (0.60) 0.67 (1.7)

21.4 (17.2) 4.6 (10.4) 83.9% 48% 19% 4.3 (7.6) 4.3 (5.7) 0 (0) 3.4 (3.2) 0.07 (0.32) 0.5 (1.8) 3.7 (7.8) 9.7 (12.6) 0.14 (0.48) 0.33 (0.74)

b0.001⁎⁎⁎ 0.22 0.04⁎ 0.04⁎ b0.01⁎⁎

16.2 (13.6) 4.1 (7.7) 82.3%⁎

0.31 0.33 0.32 0.98 0.43 0.08+ 0.11 0.35 0.49 0.80

15.4 (13.3) 5.9 (8.5) 70.4% 62% 31% 7.0 (8.4) 6.2 (6.3) 0 (0) 4.9 (3.0) 0.28 (0.65) 1.5 (2.2) 3.1 (4.2) 13.2 (12.8) 0.17 (0.60) 0.90 (2.1)

69% 46% 8.9 (15.1) 10.1 (11.3) 0.03 (0.19) 6.4 (3.8) 0.03 (0.19)+ 1.4 (4.0) 3.9 (3.8) 15.1 (22.1) 0.31 (0.60) 0.45 (1.0)

24.6 (21.8) 6.0 (12.9) 82.7% 43% 14% 3.9 (6.9) 3.3 (6.0) 0 (0) 3.8 (4.0) 0.04 (0.19) 0.21 (0.96) 3.8 (9.5) 8.9 (15.0) 0.18 (0.55) 0.39 (0.83)

18.3 (10.9) 3.2 (7.1) 85.6% 52% 23% 5.0 (8.2) 5.3 (5.3) 0 (0) 3.3 (2.5) 0.10 (0.40) 0.71 (2.3) 3.5 (5.8) 10.3 (9.9) 0.10 (0.40) 0.26 (0.63)

Meal environment Television on

34%

40%

0.52

41%

24%

46%

32%

⁎ Difference between groups is significant at p b 0.05 ⁎⁎ Difference between groups is significant at p b 0.01 ⁎⁎⁎ Difference between groups is significant at p b 0.001 + Trend result at p b 0.10. a As the dinners were significantly longer than the new food occasions (average of 23.4 vs.14.8 min; p b 0.001) and parents had much more time to interact with the child, the total instances of the behavior are displayed in the table, but in order to calculate the p-value, these were divided by the length of video to compare relative frequency of behaviors.

Please cite this article as: L.R. Fries, et al., Parent-child mealtime interactions associated with toddlers' refusals of novel and familiar foods, Physiol Behav (2017), http://dx.doi.org/10.1016/j.physbeh.2017.03.001

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Table 4 Differences between reported picky- and non-picky and neophobic/non-neophobic children in mean number of observed food refusals (SD) by refusal type. Dinner

Total food refusals Turning head or leaning away from food Pushing food away Crying Spitting food out Closing/covering mouth Ignoring the food offered Refusing verbally

New food

Picky eaters (n = 29)

Non-picky (n = 31)

Picky eaters (n = 29)

Non-picky (n = 31)

Neophobic (n = 27)

Non-neophobic (n = 33)

11.0 (15.0) 1.8 (4.1) 3.9 (5.6) 0.52 (1.3) 0.83 (1.7) 0.55 (2.2) 0.59 (1.4) 2.7 (5.0)

9.3 (9.3) 1.4 (2.2) 2.6 (3.9) 0.10 (0.40)+ 1.6 (2.2) 0.30 (0.99) 0.77 (1.8) 2.4 (4.1)

16.9 (26.8) 3.0 (6.1) 4.5 (7.5) 0.36 (0.91) 1.5 (2.3) 1.0 (2.7) 0.79 (2.4) 5.6 (8.9)

12.3 (11.4) 2.2 (4.1) 3.4 (5.2) 0.06 (0.25)+ 2.4 (3.2) 0.45 (1.2) 0.68 (1.4) 3.0 (3.1)

17.5 (27.4) 3.1 (6.1) 4.4 (7.8) 0.42 (0.95) 1.6 (2.4) 1.4 (3.0) 0.73 (2.4) 6.0 (9.2)

12. 2 (11.9) 2.2 (4.3) 3.7 (5.1) 0.03 (0.18)⁎ 2.4 (3.2) 0.22 (0.49)⁎ 0.75 (1.3) 2.8 (3.4)+

Note: groups were divided by median split. For picky eating, this was on the CEBQ Food Fussiness subscale; for neophobia using the Food Neophobia Scale. ⁎ Difference between groups is significant at p b 0.05 + Trend result at p b 0.10.

offering a novel fruit or vegetable. For dinner refusals, the only significant predictor was if parents reported that they tell the child to eat something from their plate (for example, “Eat your beans.”), which is roughly equivalent to what would be coded as a neutral encouragement in the observational coding scheme (β = 0.298; p b 0.05; model r2 = 0.089). For new foods (r2 = 0.357), two variables were associated with a greater number of refusals: begging the child to eat (β = 0.382; p b 0.01) and making something else when the child does not like what is served (β = 0.271; p b 0.05); while two were associated with fewer refusals: being in another room while the child eats (β = − 0.298; p b 0.05) and offering the child additional servings (β = −0.247; p b 0.05). Of these four models, the use of observed behaviors during the novel food scenario explained the most variance (75%) in food refusals during this meal. The next most predictive model was the observed behaviors during the typical dinner, which explained 39% of variance, followed closely by the reported feeding practices associated with food refusals in the novel food situation (36%). The reported feeding practices explained the least variance in the food refusals at dinner, at only 9%.

4. Discussion 4.1. Differences between typical meals and introducing a new food Parents employ a wide variety of feeding practices during mealtimes, often combining both autonomy-supporting prompts to eat and those that are more coercive or controlling. When parents introduce a new food, the main change in these practices is to increase the number, proportion, and frequency (per minute) of autonomy-supportive prompts to eat. The increase in the proportion of autonomy-supportive prompts suggests that parents may be aware that gentler prompting techniques are more effective when introducing new foods.

Table 5 Correlations between type of prompt to eat and food refusals in children in the group scoring higher on the CEBQ food fussiness subscale and those scoring lower. Non-picky (n = 31)

Picky eaters (n = 29)

Of note, parents were less likely to eat together with the child during the occasion where they introduced a new fruit or vegetable, which makes it more difficult to model eating the food: a technique which has previously shown to be effective in encouraging children to eat a target food [15,23]. Although the instructions for the novel food task did not specify how the novel food should be served, it is possible that parents thought that they should serve the novel food by itself (i.e., not integrated into a meal), as the majority of families served the food in this way. This may also explain why the parents often did not eat with the child. Future interventions aiming to increase dietary variety by introducing new foods might start by encouraging family meals and modeling.

4.2. Picky eating, neophobia, and food refusals Although there was substantial overlap between the “more picky” and the “more neophobic” groups, some children were categorized differently by the two measures: 6 children were categorized as “more picky” but not neophobic, and 4 children were “more neophobic” but less picky. This overlap may be partially explained by the fact that the Food Fussiness subscale of the CEBQ includes some items that address food neophobia (e.g., “My child refuses new foods at first”) in addition to items focusing on other aspects of picky eating (“My child is difficult to please with meals”). To test whether these particular items drove the categorization of the children using the food fussiness scale, we regrouped the children using only the two non-neophobia items [42]. The majority of children were categorized the same way by the nonneophobic items only (88%), but seven children were categorized differently (three moved from “low” to “high” group, and four in the other direction). This suggests that the neophobia items alone cannot completely account for the categorization of the children on the food Table 6 Observed and reported feeding practices that are significant predictors of observed food refusals using a stepwise regression model. Observed behaviors Behavior

Reported behaviors Beta (β)

2

# ASP # CCP Ratio ASP/total prompts

Food refusals Dinner

Food refusals New food

Food refusals Dinner

Food refusals New food

0.477⁎⁎ 0.279 −0.147

0.495⁎⁎ 0.367⁎ −0.242

0.705⁎⁎⁎ 0.829⁎⁎⁎,a

0.647⁎⁎⁎ 0.919⁎⁎⁎,a −0.574⁎⁎

−0.199

⁎ Significant at the p b 0.05 level. ⁎⁎ Significant at p b 0.01. ⁎⁎⁎ Significant at p b 0.001. a Significantly stronger correlation than in non-picky group.

Dinner: r = 0.389 Total CCP New food: r2 = 0.752 Total CCP Offer additional servings Praise Restriction

Behavior

Beta (β) 2

0.543⁎⁎⁎ 0.791⁎⁎⁎ −0.163⁎ −0.240⁎⁎ −0.155⁎

Dinner: r = 0.089 Tell child to eat something New food: r2 = 0.357 Beg child to eat Make something else for child Being in another room while child eats Offer additional servings

0.298⁎ 0.382⁎⁎ 0.271⁎ −0.298⁎ −0.247⁎

⁎ Significant at the p b 0.05 level. ⁎⁎ Significant at p b 0.01. ⁎⁎⁎ Significant at p b 0.001.

Please cite this article as: L.R. Fries, et al., Parent-child mealtime interactions associated with toddlers' refusals of novel and familiar foods, Physiol Behav (2017), http://dx.doi.org/10.1016/j.physbeh.2017.03.001

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L.R. Fries et al. / Physiology & Behavior xxx (2017) xxx–xxx

fussiness questionnaire. It also reinforces that parents tend to endorse both neophobia-related and other picky eating behaviors together. Overall, when a median split on the CEBQ food fussiness scale (picky eating) or the Child Food Neophobia Scale (neophobia) were used to divide children into more or less picky groups, there were no group differences in food refusals. One possible explanation for this could be that some children are mis-categorized as picky eaters, with parents overestimating the children's mealtime difficulties. This would be consistent with recent studies showing that parents of picky eaters overestimated their children's avoidance of certain food categories [31] and that parents may generalize a child's global pickiness based on rejections of just a few foods (e.g., not liking onions; [46]). Another possibility, especially for the dinner meal, could be that parents of picky eaters choose to serve their children foods that are more likely to be accepted, thereby reducing the number of food refusals. This is supported by our finding from the questionnaire items, showing that parents who were likely to prepare an alternative meal for their child had children who made more food refusals when presented with a novel food. Although there were no overall differences between the more picky and less picky groups for overall food refusals, when these were broken down into type of refusal, the picky eating and neophobic groups were more likely to cry to refuse a food, and the more neophobic children were also more likely to use verbal refusals or cover their mouth to refuse new foods. It is possible that these particular refusal types are more salient and disturbing to parents, and a crying child at mealtimes may be more likely to be labeled as a “picky eater” than one who simply ignores the spoon in front of him. Alternatively, it is possible that picky eaters have learned that when other forms of refusals are ignored by persistent parents who continue to offer foods, crying can be an effective technique to stop their parents' prompts to eat. 4.3. Feeding practices and associations with food refusals More prompts to eat (of any type) were generally associated with more food refusals from the child. This is not surprising, as children would be more likely to make an obvious refusal of a food (e.g., say “no” or push the food away) after the parent has asked them to eat the food. If the parent does not obviously promote the food, the child may simply not eat it, rather than actively rejecting it. For the new food situation, a higher proportion of autonomy-supportive prompts was associated with fewer food refusals, suggesting that these types of prompts to eat may be less likely to provoke a food refusal than more controlling techniques. This is consistent with previous studies finding that the use of pressure by parents is associated with more picky eating by children [17–19], potentially through decreasing children's enjoyment of eating [47]. The findings are also consistent with studies showing that some autonomy-supportive prompts, such as modeling and reasoning can be effective in convincing children to eat foods without refusals and to have diets higher in fruits and vegetables [14,15,21]. Parents of pickier eaters used a lower proportion of autonomy-supportive prompts to eat than did parents of less picky eaters. Further, separate comparisons of the relationships between feeding practices and food refusals in these two groups found that the association between type of prompt and refusals is even greater in picky eaters, suggesting that this population may be particularly sensitive to parents' feeding practices and more likely to react with a refusal to coercive and controlling prompts than would a non-picky eater. As these results show that parents of perceived picky eaters use a higher proportion of controlling prompts, which in turn are particularly strongly associated with more food refusals, these families may benefit the most from guidance about how to use autonomy-supportive prompts. Overall, observed parent behaviors were better predictors of children's food refusals than were parents' reported feeding practices. This could suggest that parents' report of their feeding practices is not accurate, or simply that the observed behaviors, which were recorded

from the same meal situation, reflect a more proximate factor. As the relationship between children's eating behaviors and parents' feeding practices is reciprocal, the feeding practices used within a particular meal are likely more relevant to refusals within that meal than more globally-assessed “typical” behavior, as assessed on a questionnaire. Although the observational results point to a relationship specifically between coercive and controlling prompts and food refusals, when we explored parents' reported behaviors that were associated with these refusals, we found that the best predictor was parents' report of “telling my child to eat something on the plate”, rather than some of the more coercive-sounding items on the questionnaire (e.g., offering rewards for eating, warning that other foods will be taken away). It is possible that this questionnaire item reflects parents' use of pressure in the real world (“telling” the child to do something as a command), or that parents underestimate the amount of force or pressure behind their prompts, as observed. To disentangle this, future studies could assess the accuracy of parents' reported feeding practices compared with observed feeding behaviors, and explore which questionnaire items are most closely associated with specific observed behaviors. Parents who reported that they make their child another food if he doesn't like what is served had children who were more likely to reject new foods, which is consistent with studies suggesting that making special meals for the child could perpetuate their limited diet and avoidance of new foods [24]. 4.4. Advantages and limitations This study is novel in its use of behavioral observation of parent-child interactions during two different naturalistic in-home mealtime situations with a focus on feeding practices associated with food refusals. This observational approach allowed us to measure both parent- and child behaviors in an objective and quantitative way, without the potential biases of parent-report questionnaires. When parents' observed behaviors were used as predictors in a regression model to predict children's food refusals, the models explained a larger portion of the variance (39% of variance in dinner refusals and 75% for new foods) compared to the models using parents' reported behaviors (9% and 36%, respectively). Further, as the types of parental observed behaviors and reported behaviors associated with children's food refusals differed somewhat, this highlights the value of research using behavioral observation methods, as it may identify associations between outcomes such as food refusals with parental behaviors that they may not be aware of or able to quantify. It can also identify potential differences between the reported behaviors associated with food refusals (in this case, “telling my child to eat something”) and those observed (use of pressure, rewards, threats), which can help future educational initiatives to target behaviors that may require additional parental awareness before change. One limitation of the study lies in the cross-sectional nature of the research, which makes it impossible to draw causal conclusions. Although it has been theorized that parents' controlling prompts to eat could increase picky eating (e.g., [3,13,18]), including the observed food refusals, it is also plausible that children's food refusals could cause parents to increase their use of prompts and to use more controlling prompts [40,45]. Recent research on feeding practices [28,41,51], suggests that the relationship is likely bidirectional: that the child may refuse a food, to which the mother reacts by trying a more controlling prompt to eat, followed by more refusals from the child. Future experimental studies could explore whether use of autonomy-supportive prompts would induce fewer refusals than coercive-controlling ones on the long term, or whether an intervention to decrease parents' use of controlling prompts would reduce the frequency of child food refusals. Another limitation of the current study was the use of median splits to divide children in to a picky(er)/less picky and (more) neophobic/less neophobic groups. As there are no set or recommended cutoff points on these measures for identifying picky/neophobic children, and the sample size was limited, a median split was applied to have a sufficient number of children in both subgroups, but a median split may not be sensitive enough to

Please cite this article as: L.R. Fries, et al., Parent-child mealtime interactions associated with toddlers' refusals of novel and familiar foods, Physiol Behav (2017), http://dx.doi.org/10.1016/j.physbeh.2017.03.001

L.R. Fries et al. / Physiology & Behavior xxx (2017) xxx–xxx

identify group differences in picky eaters, as evidenced by the large within-group variance. Future research studies might explore if there is a more meaningful cutoff point to identify picky eaters that will also show more significant behavioral differences between groups. Future research will need to explore to what extent the current findings can be generalized. The study population was quite diverse and reflected families from both urban and rural settings, distributed across the United States. However, as all families needed to have a stay-athome parent to collect the data, their feeding practices may differ from families in which alternative caregivers (e.g., grandparents, nannies) typically feed the child, or when children are in daycare. Further, although parents acted quite naturally during the dinner situation, as the focus of the study was on the child and the parents were not selfconscious about their own behavior, it may be that the instructions for the “new food” scenario prompted parents to introduce the food in a different way than they might normally have done. Although the instructions were vague about how to introduce the new fruit or vegetable, many parents chose to do so outside of a main meal (e.g., lunch or dinner), which may or may not be representative of how parents would typically introduce a novel food. 5. Conclusions Parents' reported picky eating was not associated with an increase in overall food refusals, although reported neophobia was associated with more uses of crying, pushing food, or verbally refusing a new food. Although children's behavior did not differ dramatically between the picky and less-picky groups, parents of pickier eaters tended to use a lower proportion of autonomy-supportive prompts, and these families also showed a stronger association between the use of controlling prompts and food refusals. These families may benefit the most from interventions aiming to promote autonomy-supportive feeding practices, such as the use of modeling and reasoning, and to reduce the use of controlling practices, but whether this would reduce objectively-measured food refusals would need to be tested. Acknowledgments We would like to acknowledge the valuable inputs of Brigitte Schlosser and Dimitri Gerebtzoff in the development of the coding scheme. We would also like to thank the behavioral coders for their hard work on this project as well as the families for their participation. This study was funded by Nestec. References [1] E. Addessi, A.T. Galloway, E. Visalberghi, L.L. Birch, Specific social influences on the acceptance of novel foods in 2-5-year-old children, Appetite 45 (2005) 264–271. [2] H. Bergmeier, H. Skouteris, M.M. Hetherington, Systematic research review of observational approaches used to evaluate mother-child mealtime interactions during preschool years, Am. J. Clin. Nutr. (2015)http://dx.doi.org/10.3945/ajcn.114.092114. [3] J. Blissett, Relationships between parenting style, feeding style and feeding practices and fruit and vegetable consumption in early childhood, Appetite 57 (3) (2011) 826–831, http://dx.doi.org/10.1016/j.appet.2011.05.318. [4] J. Blissett, A. Fogel, Intrinsic and extrinsic influences on children’s acceptance of new foods, Physiol. Behav. 121 (2013) 89–95, http://dx.doi.org/10.1016/j.physbeh.2013. 02.013. [5] M.M. Boquin, S. Smith-Simpson, S.M. Donovan, S.Y. Lee, Mealtime behaviors and food consumption of perceived picky and nonpicky eaters through home use test, J. Food Sci. 79 (12) (2014) S2523–S2532. [6] C.L. Brown, E.B.V. Schaaf, G.M. Cohen, M.B. Irby, J.A. Skelton, Association of picky eating and food neophobia with weight: a systematic review, Childhood Obes. 12 (4) (2016) 247–262, http://dx.doi.org/10.1089/chi.2015.0189. [7] S. Cardona Cano, H. Tiemeier, D. Van Hoeken, A. Tharner, V.W.V. Jaddoe, A. Hofman, ... H.W. Hoek, Trajectories of picky eating during childhood: a general population study, Int. J. Eat. Disord. 48 (6) (2015) 570–579, http://dx.doi.org/10.1002/eat. 22384. [8] B.R. Carruth, J.D. Skinner, Revisiting the picky eater phenomenon: neophobic behaviors of young children, J. Am. Coll. Nutr. 19 (6) (2000) 771–780. [9] L.J. Cooke, S. Carnell, J. Wardle, Food neophobia and mealtime food consumption in 4–5 year old children, Int. J. Behav. Nutr. Phys. Act. 3 (1) (2006).

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Please cite this article as: L.R. Fries, et al., Parent-child mealtime interactions associated with toddlers' refusals of novel and familiar foods, Physiol Behav (2017), http://dx.doi.org/10.1016/j.physbeh.2017.03.001