AJSLP
Research Article
Novel Mealtime Duration Measures: Reliability
and Preliminary Associations With Clinical
Feeding and Swallowing Performance in
Self-Feeding Children With Cerebral Palsy
Avinash Mishra,a Justine J. Sheppard,a Cagla Kantarcigil,b
Andrew M. Gordon,a and Georgia A. Malandrakib
Purpose: The purpose of this study is to examine (a) the
reliability of newly developed measures of mealtime duration
and (b) their relationship to clinical feeding/swallowing
performance in children with spastic cerebral palsy (SCP).
Method: Seventeen self-feeding children (9 boys, 8 girls) with
SCP (age range = 5;1 [years;months] to 17;6, Gross Motor
Function Classification System range = I–IV) were assessed
during mealtimes using the Dysphagia Disorder Survey (DDS;
Sheppard, Hochman, & Baer, 2014). Children were divided into
2 groups, children with primarily unilateral or bilateral brain
involvement. Duration measures included mealtime duration
and total sip/bite duration for each bolus type (liquid and solid).
Results: Excellent intra- and inter-rater reliability for all
duration measures was observed (intraclass correlation
coefficient [ICC] = 1.00 and 0.955, respectively, for mealtime
duration; ICC = 1.00 and 0.963, respectively, for solid/bite
duration; ICC = 1.00 and 0.957, respectively, for liquid/sip
duration). Positive correlations were found between total
C
erebral palsy (CP) is the most common neuro-
motor disability of childhood with a prevalence of
2–3/1,000 births (Kirby et al., 2011). CP has been
described as a nonprogressive encephalopathy affecting
movement and postural development and has been asso-
ciated with several comorbidities involving cognition,
a
Department of Biobehavioral Sciences, Teachers College, Columbia
University, New York, NY
b
Department of Speech, Language, & Hearing Sciences, College of
Health and Human Sciences, Purdue University, West Lafayette, IN
Correspondence to Georgia A. Malandraki: malandraki@purdue.edu
Avinash Mishra is now at the Speech-Language Pathology and Audiology,
Hunter College, City University of New York, New York, NY.
Editor: Krista Wilkinson
Associate Editor: Julie Barkmeier-Kraemer
Received November 14, 2016
Revision received May 10, 2017
Accepted August 3, 2017
https://doi.org/10.1044/2017_AJSLP-16-0224
American Journal of Speech-Language Pathology • Vol. 27 • 99–107 • February 2018 • Copyright © 2018 American Speech-Language-Hearing Association
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mealtime duration and DDS Part 1, rs = .514 [.045–.797],
p = .035; Part 2, rs = .528 [.064–.804], p = .029; and total
scores, rs = .665 [.271–.868], p = .004, and between total
solid/bite duration and DDS Part 1, rs = .579 [.137–.828],
p = .015; Part 2, rs = .620 [.199–.847], p = .007; and total
scores, rs = .762 [.444–.909], p < .001. Children with unilateral
brain involvement exhibited significantly lower DDS total
( p = .049) and Part 2 scores ( p = .026), indicating better
feeding/swallowing performance/skills. They also had
shorter mealtime duration ( p = .019) and solid/bite duration
( p = .025) compared with children with bilateral involvement.
Conclusions: Our new mealtime duration measures are
reliable and correlate with feeding/swallowing performance
in a sample of self-feeding children with SCP. Therefore,
they may be useful supplements to feeding/swallowing
assessments for this population.
Supplemental Material: https://doi.org/10.23641/
asha.5715076
somatosensation, communication, and musculoskeletal
function (Rosenbaum et al., 2007).
Feeding and swallowing disorders (dysphagia) are
also reported in 19% to up to 99% of children with CP
(Calis et al., 2008; Fung et al., 2002; Parkes, Hill, Platt,
& Donnelly, 2010). In pediatrics, feeding and swallowing
are often viewed as a continuum, because they are inti-
mately related (Malas, Trudeau, Chagnon, & McFarland,
2015), and comprise four coordinated phases: preoral, oral,
pharyngeal, and esophageal. Dysphagia in CP can affect
all phases of swallowing and may include difficulty in plac-
ing and containing the food in the mouth, oral motor dis-
coordination, reduced oropharyngeal strength, abnormal
tone, pathological oral reflexes, and poor texture advance-
ment, and may result in coughing, choking, and nutritional
Disclosure: Justine J. Sheppard discloses that she developed the Dysphagia Disorder
Survey (one of the instruments used in this study) and is a member of the Nutritional
Management Associates, LLC. The other coauthors have declared that no competing
interests existed at the time of publication.
99
 failure (Calis et al., 2008; Rogers, Arvedson, Buck, Smart,
& Msall, 1994). Without proper treatment, dysphagia in
CP can significantly increase the risk for recurrent aspiration
leading to respiratory infections, lung disease, failure
to thrive, and death (Calis et al., 2008; Lefton-Greif &
McGrath-Morrow, 2007; Rogers et al., 1994).
Feeding and swallowing assessments in CP involve
multiple components, including medical and developmental
history, clinical feeding observations, cranial nerve exami-
nations and, when necessary, instrumental evaluations
(Arvedson, 2008). In addition, mealtime duration is often
assessed. Clinically, mealtime duration in excess of 20–30 min
has been considered as a possible sign of dysphagia, as well
as inefficient and insufficient nutritional intake (Arvedson,
2008). However, the empirical evidence/literature supporting
this statement for children with CP is contradictory.
Studies of mealtime duration that have relied on
parent reports have reported mixed results. In a study by
Erkin, Culha, Ozel, and Kirbiyik (2010), a representative
sample of 120 children with CP and parent-reported feeding
dysfunction, aged 2–12 years, had significantly longer
mealtime durations compared with their counterparts with-
out feeding difficulties (114 min/day vs. 84 min/day, respec-
tively). Likewise, Wilson and Hustad (2009) descriptively
reported that five out of 37 children with CP and oral
motor involvement (11–58 months old), as determined by
parental responses to a 12-item feeding and swallowing ques-
tionnaire developed by the authors, required 30–60 min to
consume a meal. In contrast, Benfer et al. (2014) analyzed
parental responses in 3-day food logs and did not find
significant relationships between mealtime duration and
severity of dysphagia in a sample of 130 preschool children
aged 18–36 months with CP. These mixed findings may be
due to the fact that these studies relied solely on caregiver
reports (Benfer et al., 2014; Erkin et al., 2010; Wilson &
Hustad, 2009).
Reilly and Skuse (1992) performed direct mealtime
observations in 12 children with CP aged 15–39 months
and 12 age-matched controls. Mealtime duration was defined
as the interval between the presentation of the first bolus and
the mother’s signal of meal conclusion. All mothers in this
study were instructed to feed their children, and no signifi-
cant differences were found between groups. The same
research group used parent questionnaires and a direct
video-recorded assessment in another study of 49 children
with CP between 1 year and 6 years of age (Reilly, Skuse,
& Poblete, 1996). They observed that children with severe
oral motor dysfunction demonstrated shorter mealtime
durations than children with milder oral motor deficits.
They also reported that directly measured durations were
approximately 10 min shorter than parent-reported dura-
tions. The only prior study, to our knowledge, that looked
into mealtime subcomponents (i.e., bolus consistencies,
such as liquids, solids, and semisolids) in children with CP was
a study by Gisel and Alphonce (1995). These investigators
aimed to classify feeding impairments in a representative
sample of 100 children across CP types on the basis of dura-
tion of mealtime subcomponents (solid, puree, and viscous
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foods, but not liquids). Duration was measured from place-
ment of the bolus into the oral cavity until the swallow
was visually noted. Prolonged duration among solid, puree,
and viscous food types was observed as compared to norma-
tive data obtained by the same researchers in a prior study
(Gisel, 1988).
While these studies provide objective data, they have
used variable measurements for mealtime duration on the
basis of caregiver reports or responses for mealtime conclu-
sion (Erkin et al., 2010; Gisel & Alphonce, 1995; Reilly
& Skuse, 1992; Wilson & Hustad, 2009). Also, mealtime
subcomponents have been investigated only by one prior
study, which used visual detection of the swallow (Gisel &
Alphonce, 1995). In children with CP and known aberrant
motor control and oropharyngeal discoordination, visual
detection of the swallow (typically conducted by observing
the thyroid notch movement during the swallow) is extremely
challenging. It has been suggested that obtaining a valid
measure of mealtime duration can provide insight into not
only observed deficiencies but also potential for growth
(Rogers, 2004). Therefore, it is important to develop direct
mealtime duration and subcomponent measurements that
are clearly defined, highly reliable (replicable), and easy
to use. To address this gap, we aimed (a) to examine the
intra- and inter-rater reliabilities of direct measures of meal-
time duration and its subcomponents that were developed
for this study and, (b) as a measure of preliminary validity,
to determine the relationship of these objective measures
to clinical feeding and swallowing performance in children
with spastic CP who presented with bilateral or unilateral
brain involvement. It is well known that feeding and
swallowing require the highly complex sensorimotor
coordination of multiple structures, muscles, brainstem
centers, and areas in the cortex and subcortex bilaterally
(Hamdy, Rothwell, Aziz, & Thompson, 2000; Humbert
& Joel, 2012; Lowell, Reynolds, Chen, Horwitz, & Ludlow,
2012; Malandraki, Sutton, Perlman, & Karampinos, 2010).
In children with unilateral early brain injuries manifesting
as CP, we recently showed that adaptive contralesional
neuroplastic compensations/communications for func-
tional swallowing are seen when sensorimotor areas of
one hemisphere are affected (Mourao et al., 2017). It
is only logical to assume that these neuroplastic effects
would be less pronounced in children with bilateral
lesions, although data are still emerging. Therefore, from
a neurophysiological and neuropathological standpoint,
it is important to investigate differences between these two
groups.
We hypothesized that longer mealtime durations
would be associated with increased clinical signs of feeding
and swallowing difficulties. In addition, given what we
know about the neural control of swallowing (Hamdy
et al., 2000; Humbert & Joel, 2012; Lowell et al., 2012;
Malandraki et al., 2010; Mourao et al., 2017), we hypothe-
sized that children with primarily bilateral brain involvement
manifesting as bilateral spastic CP (BSCP) would demon-
strate more signs of feeding and swallowing dysfunctions
and significantly longer mealtime durations than children
 Table 1. Operational definitions of mealtime duration components.
with primarily unilateral brain involvement manifesting
as unilateral spastic CP (USCP).
Component Start time End time

Total mealtime Frame at which first Frame at which

Method duration bolusa or bolus- child signaled
This study was approved by the university institutional containing utensil meal conclusion
touched lips
review board. Written informed consent was obtained from Individual Frame at which Frame at which
all legal guardians and, when applicable, from minors prior solid/bite solid bolus/bolus- subsequent
to participation. All of the children provided assent. duration containing utensil bolus/ bolus-
touched lips containing utensil
touched lips
Participants Individual Frame at which Frame at which
liquid/sip liquid bolus/bolus- subsequent
Children were recruited from a convenience sample duration containing utensil bolus/ bolus-
derived from two camps of a CP research center during touched lips containing utensil
touched lips
two summers (2014/2015). The camps focused on upper
Total solid/ Sum of individual solid/bite durations
and lower extremities and speech interventions, respec- bite duration
tively. Inclusion criteria included (a) a diagnosis of spastic Total liquid/ Sum of individual liquid/sip durations
CP (criterion to participate in camps), (b) the ability to sip duration
self-feed, and (c) the ability to be mainstreamed in school a
Bolus: food or liquid being consumed.
(criterion to participate in camps). Exclusion criteria included
(a) additional neurological diagnoses, (b) health concerns
unassociated with CP, and (c) inability to provide assent.
Although the criterion for a diagnosis of spastic CP was
Mealtime duration components were operationally
a camp participation criterion, given the wide variability of
defined (see Table 1). As indicated in Table 1, total mealtime
CP, initiating this work by focusing on a specific subgroup
duration was measured from the frame at which the first
with CP is believed to allow more valid interpretations
bolus/bolus-containing utensil touched the lips until the
of the findings and form a foundation for studying other
frame at which the child signaled mealtime conclusion.
groups with CP in the future. In addition, children were
Composite durations for liquids and solids were the sum
divided into two groups, on the basis of neurological/brain
of all individual liquid/sip durations and solid/bite durations,
lesion information provided via neurological reports and/or
respectively. Individual durations were not intended as an
magnetic resonance imaging reports. The groups included
overall measure but rather to contribute to these composite
children with primarily unilateral brain involvement mani-
scores. In this sample, liquids included water, energy drinks,
festing as a group with USCP and children with primarily
lemonade, and juice. Solids were defined as any consistency
bilateral brain involvement manifesting as a group with
requiring manipulation in the oral cavity prior to swallowing,
BSCP.
such as meat, bread, yogurt, and fruit. Supplemental Mate-
rial S1 lists all foods and liquids consumed by each child.
Procedure The duration measures were developed following a review
During the camps, allotted duration for lunchtime of the literature and were refined through consensus between
was 60 min/day. Lunches occurred in group therapy rooms the principle investigator (last author) and the first and sec-
(580 cm × 600 cm). Children were seated at a table with ond authors. The video-viewing software timer was used
their peers and fed themselves foods and liquids that they to record exact start and end times. These definitions were
brought from home. Children were allowed to socialize based on information that can be easily and accurately
with each other as they would in natural environments, detected visually during live evaluations and/or video record-
such as home or school. A single meal on day 6 of the ings. A certified speech-language pathologist (Rater 1)
2014 camp and on day 10 of the 2015 camp were selected and one of two trained speech-language pathology students
for analysis due to maximum participant attendance and (Raters 2 and 3) independently analyzed all video record-
availability of investigators. ings to obtain duration measures.
High-definition cameras (Canon VIXIA HF R500
3.28 MP Camcorder or SONY Handycam HDR-CX240
2.51 MP Camcorder) were used to obtain video recordings. Feeding and Swallowing Evaluations
Cameras were placed on adjustable tripod stands positioned Clinical feeding and swallowing performance was
directly in front of the children in the anterior–posterior evaluated using the Dysphagia Disorder Survey (DDS),
plane (60 cm from each child). A view of each child and a clinical dysphagia assessment with good psychometric
his or her food and liquid was obtained throughout the properties that has been standardized on individuals with
meal. No more than two children were recorded from each developmental disabilities, including children with CP
individual camera. The camera view was leveled with the (Sheppard, Hochman, & Baer, 2014). With respect to the
height of the child’s head. DDS data collection and scoring, our methods have been

Mishra et al.: Mealtime Duration in Cerebral Palsy 101

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 described previously in detail (Kantarcigil, Sheppard,
Gordon, Friel, & Malandraki, 2016). In short, the DDS has
two parts and is scored using a binary system (0 = normal,
1 = abnormal) as the rater observes and scores the partici-
pant’s management of liquid and nonchewable (puree and
grainy) and chewable foods in a natural setting. DDS Part 1
has a maximum score of 15 and contains variables related
to preoral swallowing components and feeding, such as diet,
independence, adaptive utensils used, positioning, postural
control, and feeding techniques. DDS Part 2 has a maximum
score of 19 and contains a task analysis of oropharyngeal
swallowing competencies, including orienting to foods, oral
reception and containment, oral transit, chewing, oropharyn-
geal swallow efficiency, and postswallow signs of difficulty,
such as wet voice or coughing. DDS total scores range from
0 to 34. Statistical analysis has indicated that a DDS total
score of ≥ 3 achieves optimum screening sensitivity and spec-
ificity, indicating the probability of a feeding/swallowing dis-
order and the need for further assessment (Sheppard, 2013;
Sheppard et al., 2014). DDS scoring was conducted live
by a certified speech-language pathologist and two doc-
toral speech-language pathology students, all of whom were
trained and certified in DDS administration and scoring.
Videotaped data from four participants were reevaluated by
the same rater (Rater 1) and an additional rater (Rater 2)
to determine inter- and intra-reliability.
Statistical Analyses
Statistical analyses were performed using SPSS sta-
tistical software (IBM Corp. Released 2013. IBM SPSS
Statistics for Macintosh, Version 22.0.). Intra- and inter-
rater reliability measures were assessed through intraclass
correlation coefficients (ICCs). Given the relatively small
sample size and nonnormal distribution of the data, non-
parametric tests were used for the remaining analyses.
Spearman rank order correlations were used to determine
correlations between components of mealtime duration
and DDS scores and post hoc correlations between meal-
time durations and Gross Motor Function Classification
System (GMFCS) or Manual Ability Classification System
(MACS) levels. A Bonferroni-corrected Mann–Whitney
test was used to determine differences between the groups
with USCP and BSCP in demographic data, including age,
sex, GMFCS level, and MACS level. The Kruskal–Wallis
H Test was used to examine differences between the groups
with USCP and BSCP regarding duration measures and
DDS scores. Given that Spearman rank order correlations
are measures of effect size, additional calculations were per-
formed to determine eta squared values of effect size for the
Kruskal–Wallis H Test (Fritz, Morris, & Richler, 2012).
The significance threshold was set at p < .05.
Results
Demographics and DDS Results
Of a total of 36 children participating in both summer
camps, 17 children (9 boys and 8 girls) fulfilled the criteria
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and assented to participate. Ten participants had been
diagnosed with primarily unilateral brain involvement man-
ifesting as USCP and seven with primarily bilateral brain
involvement manifesting as BSCP. As reported earlier, uni-
lateral versus bilateral brain involvement division was based
on neurological/brain lesion information provided via neu-
rological reports and/or magnetic resonance imaging re-
ports. Demographic information and clinical scores are
presented in Table 2. Gross motor and manual ability were
assessed by trained physical and occupational therapists
using the GMFCS and the MACS, respectively (Eliasson
et al., 2006; Palisano et al., 1997). DDS total scores ranged
from 3 to 9 (M [SD] = 6 [2]) for children with USCP and
from 5 to 17 (M [SD] = 9 [4]) for children with BSCP.
Therefore, all children met or exceeded the DDS scoring
criterion of 3, indicating probability of swallowing and
feeding disorders.
Reliability
Intra- and inter-rater reliability measures were deter-
mined using 100% of the data for mealtime duration com-
ponents, which were the focus of this work, and 25% of
the data for DDS components. ICCs revealed excellent
intra- and inter-rater reliability for total mealtime duration
(1.00 and 0.955, respectively), total solid/bite duration (1.00
and 0.963, respectively), and total liquid/sip duration (1.00
and 0.957, respectively). Excellent intra-rater and inter-rater
reliabilities were also observed for DDS Part 1 (1.00 and
1.00, respectively), Part 2 (0.977 and 0.903, respectively),
and DDS total (0.991 and 0.950, respectively).
Correlational Analyses
Significant positive correlations were found between
total mealtime duration and DDS Part 1 (rs = .514; p = .035),
DDS Part 2 (rs = .528; p = .029), and DDS total scores
(rs = .665; p = .004; see Figure 1). In addition, significant
positive correlations were observed between total solid/
bite duration and DDS Part 1 (rs = .579; p = .015), Part 2
(rs = .620; p = .007), and DDS total scores (rs = .762; p < .001;
see Figure 2). No significant relationships were observed
between total liquid/sip duration and DDS Part 1 (rs = −.250;
p = .333), Part 2 (rs = −.103; p = .694), or DDS total scores
(rs = −.041; p = .876).
To further assess the potential impact of functional
gross motor and manual ability classification levels (GMFCS
and MACS) on mealtime durations, we also examined addi-
tional correlations between GMFCS levels and mealtime
durations and MACS levels and mealtime durations. GMFCS
level correlated with total mealtime duration (rs = .607;
p = .010) and total solid/bite duration (rs = .579; p = .015),
but not with total liquid/sip duration (rs = .221; p = .393).
MACS level was not correlated with total mealtime dura-
tion (rs = .259; p = .315), total solid/bite duration (rs =
.145; p = .579), or total liquid /sip duration (rs = −.012;
p = .964).
 Table 2. Sample characteristics and Dysphagia Disorder Survey (DDS) scores.

Brain Motor GMFCS MACS

Child Sex Age involvement involvement level level DDS1 DDS2 DDST

1 F 7;4 Left Hemiplegia I I 3 4 7

2 F 15;8 Left Hemiplegia I II 5 2 7
3 M 9;11 Left Hemiplegia I I 3 2 5
4 F 6;6 Left Hemiplegia I I 5 4 9
5 M 8;5 Right Hemiplegia I II 5 3 8
6 F 17;6 Left Hemiplegia I III 2 1 3
7 M 12;9 Left Hemiplegia I I 2 1 3
8 F 6;9 Left Hemiplegia I II 2 4 6
9 M 7;4 Right Hemiplegia II I 2 3 5
10 M 9;0 Left Hemiplegia II III 3 5 8
11 M 11;8 Bilateral Quadriplegia III II 4 13 17
12 M 7;8 Bilateral Diplegia III II 4 5 9
13 F 5;1 Bilateral Diplegia III II 4 6 10
14 F 11;3 Bilateral Quadriplegia IV IV 5 6 11
15 F 17;5 Bilateral Diplegia III I 2 3 5
16 M 7;8 Bilateral Diplegia III II 2 6 8
17 M 10;9 Bilateral Quadriplegia IV III 4 2 6

Note. Age is reported in years;months. GMFCS = Gross Motor Function Classification System; MACS = Manual Ability
Classification System; DDS1 = DDS Part 1; DDS2 = DDS Part 2; DDST = DDS total; F = female; M = male.

Between-Groups Analyses groups for total liquid/sip duration, χ2 = 0.038; p = .845;

Children with USCP and BSCP were well matched
with no significant differences in age, sex, or MACS level
(see Table 3). However, a significant between-groups dif-
ference was detected in GMFCS level with children with
BSCP presenting with overall higher GMFCS levels (see
Table 3). Children with USCP had significantly lower
DDS total, χ2 = 3.866; p = .049; η2 = .242, and DDS Part 2
scores, χ2 = 4.930; p = .026; η2 = .308, but no significant
differences were observed on DDS Part 1 scores, χ2 = 0.311;
p = .577; η2 = .019, compared with children with BSCP (see
Table 4). Also, children with USCP exhibited significantly
shorter total mealtime duration, χ2 = 5.486; p = .019;
η2 = .343, and total solid/bite duration, χ2 = 5.038; p = .025;
η2 = .315. No significant differences were observed between
η2 = .002 (see Table 4). On average, children with USCP
consumed their meal in 21 min ± 7 min, while children with
BSCP required 31 min ± 8 min. This was a significant dif-
ference ( p = .019). In addition, no significant between-
groups difference was detected for total number of foods/
liquids consumed (z = −0.830, p = .407).
Discussion
Overview of Results
This study examined the reliability of newly developed
objective mealtime duration measures and their relationship
to clinical signs of feeding and swallowing difficulties in a
sample of self-feeding children with CP. Our findings suggest

Figure 1. Correlations between total mealtime duration and DDS scores. DDS = Dysphagia Disorder Survey. *p < .05.

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 Figure 2. Correlations between total solid/bite duration and DDS scores. DDS = Dysphagia Disorder Survey. *p < .05.
that these measures are reliable and show preliminary associ-
ations with clinical dysphagia signs for this population.
Specifically, reliability testing revealed excellent
intra- and inter-rater agreement for total mealtime duration
(ICCs = 1.00 and 0.955, respectively), total solid/bite dura-
tion (ICCs = 1.00 and 0.963, respectively), and total liquid/
sip duration (ICCs = 1.00 and 0.957, respectively), sug-
gesting that these measures are highly reliable within and
between raters. We developed these measurements to be
practical in a clinical setting, while also being accurate dur-
ing live evaluations and/or video recordings. Direct meal-
time duration has been assessed in prior research with
variable results. Gisel and Alphonce (1995) examined dura-
tion of mealtime subcomponents by visually detecting the
swallow through video-recorded analysis and did not report
reliability of their data; visual detection of the pharyngeal
swallow in children without the use of instrumental evalua-
tion is extremely challenging and prone to inaccurate
judgment (DeMatteo, Matovich, & Hjartarson, 2005).
In particular, in children with CP, movement of the hyo-
laryngeal mechanism may not always indicate a swallow
given postural instability and oropharyngeal discoordina-
tion (Carlberg & Hadders-Algra, 2005; Krigger, 2006).
Two other studies determined total mealtime duration from
presentation of first bolus to the signaled meal conclusion
Table 3. Unilateral versus bilateral group comparisons—demographic
variables.
Variable z Value p Value
Age −0.293 .769
Sex −0.282 .778
GMFCS −3.662 .000*
MACS −1.298 .194
Note. GMFCS = Gross Motor Function Classification System;
MACS = Manual Ability Classification System.
*p < .05.
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by the caregiver and only investigated total mealtime dura-
tion (and not mealtime subcomponents; Reilly & Skuse,
1992; Reilly et al., 1996). Reilly and Skuse (1992) found
no differences between mealtime duration in preschool chil-
dren with CP and age-matched controls, whereas Reilly
et al. (1996) reported shorter mealtime durations in children
with CP and severe oral motor dysfunction compared with
children with milder oral motor deficits. Differences in
methods used to measure mealtime duration, as well as in
participants’ age ranges (1–6 years) may explain these
contradictory findings. Younger children with CP do not
typically feed themselves and rely more heavily on liquids
(that are generally cleared more quickly from the orophar-
ynx) to meet nutritional demands. Although Gangil, Patwari,
Aneja, Ahuja, and Anand (2001) identified liquids and
semisolids as the primary diet in 100 children aged 1–9 years
with CP, in our sample, even children who were the most
severely impaired (GMFCS Level IV) self-fed and ate a
variety of solids. Our measures were novel in that we used
child-controlled events that were easily and visually identifi-
able to signify the beginning and end of total mealtime
duration, as well as bite and sip durations. This was deemed
more appropriate as our sample included older children who
were self-feeding.
Furthermore, we identified positive correlations
between total mealtime duration and DDS scores, as well
as between total solid duration and DDS scores, suggesting
that mealtime duration and duration of solid consumption
are longer for children with more clinical signs of dysphagia.
These findings are in agreement with some prior studies that
have shown increased mealtime duration for children with
CP and more severe oromotor involvement (Erkin et al.,
2010; Gisel & Alphonce, 1995; Wilson & Hustad, 2009).
Our findings relating to the longer duration of solid con-
sumption with increasing clinical signs of dysphagia in CP
are also in agreement with previous research. In particular,
prolonged oral transit times across all bolus types have been
reported in children with CP, and significantly longer times
have been reported with solid boluses (Casas, McPherson,
 Table 4. Group comparisons—Dysphagia Disorder Survey (DDS) and duration measures.
Component USCP
DDS total 6.10 ± 2.08
DDS Part 1 3.20 ± 1.32
DDS Part 2 2.90 ± 1.37
Total mealtime duration (s) 1271.10 ± 412.12
Total solid/bite duration (s) 919.50 ± 337.59
Total liquid/sip duration (s) 55.10 ± 47.45
Note. USCP = unilateral spastic cerebral palsy; BSCP = bilateral spastic cerebral palsy.
*p < .05.
& Kenny, 1995). Recent research has also shown that these
children exhibit difficulty in oral containment and formation
of the bolus, at times resulting in aspiration of solids and
induction of fatigue (Kim, Han, Song, Oh, & Chung, 2013).
Therefore, children with CP are often introduced to solid
boluses at later periods than typically developing children,
which may also place them at a disadvantage in fully acquir-
ing the skills to manage these foods (Salghetti & Martinuzzi,
2012). Regarding liquid consumption, many of the children
were observed to complete sequential swallows, and there-
fore, higher total liquid/sip duration may not necessarily
reflect abnormal swallowing patterns for liquids; on the
contrary, it may even reflect greater swallowing/drinking
skills for some children. It is possible that, because for
some children this measure reflected higher swallowing
skills and, in some, poorer skills, overall, no significant
correlations were observed between DDS scores and total
liquid/sip duration. Perhaps, additional criteria are required
when measuring liquid durations to ensure that this measure
can provide consistent evaluative information. Such criteria
should be explored in future studies.
To further examine the potential impact of other
factors influencing self-feeding, such as functional gross
motor and manual ability classification levels (GMFCS
and MACS), on mealtime durations, we also examined
additional correlations between GMFCS levels and meal-
time durations and MACS levels and mealtime durations.
Similar to DDS scores, GMFCS level also significantly
correlated with total mealtime duration and total solid/bite
duration, but not with total liquid/sip duration. This finding
is not surprising if we consider that a positive relationship
between oropharyngeal dysphagia and gross motor function
has been well documented in children with CP (Benfer et al.,
2013; Calis et al., 2008; Fung et al., 2002; Kim et al., 2013).
Given the relatively small sample size, multivariate analyses
to determine the relative contributions of DDS scores versus
GMFCS levels in duration measures were not possible at
this time; however, this relationship should be further inves-
tigated with larger samples. MACS levels did not signifi-
cantly correlate with any of the duration measures in this
study. This may be because most children in our sample
(13 out of 17) had MACS levels of I or II; therefore, the
sample was relatively skewed to milder manual ability
involvement.
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BSCP p Value η2
9.43 ± 3.95 .049* .242
3.57 ± 1.13 .577 .019
5.86 ± 3.53 .026* .308
1889.14 ± 499.19 .019* .343
1328
. ± 380.92 .025* .315
50.86 ± 34.12 .845 .002
Furthermore, when comparing children with bilateral
brain involvement manifesting as BSCP and children with
unilateral brain involvement manifesting as USCP, we
saw that children in the first group exhibited significantly
higher DDS Part 2 and DDS total scores than children
in the second group, but no group differences were ob-
served for DDS Part 1. DDS Part 1 examines diet, indepen-
dence, adaptive utensils used, positioning, postural control,
and feeding techniques. Children in both groups were on
unrestricted oral diets and did not have comorbidities that
could influence DDS Part 1 scores. DDS Part 2 contains
items specific to oropharyngeal swallowing skills. Our results
suggest that children with bilateral brain involvement have
more clinical signs of dysphagia and longer mealtime dura-
tions than children with unilateral brain involvement. How-
ever, because signs of dysphagia were present in all children
(DDS scores ≥ 3) of both groups, the results further show
that clinical swallowing difficulties and mealtime duration
elements can be affected even in the milder forms of motor
involvement in CP (Benfer et al., 2014, 2015; Malandraki,
Mishra, Gordon, & Sheppard, 2014).
USCP is the manifestation of unilateral brain lesions,
including periventricular lesions and cortical dysplasia, which
result in primarily unilateral motoric deficits (Krägeloh-Mann
& Cans, 2009). BSCP may result from more systemic brain
lesions affecting both hemispheres and resulting in bilateral
motoric compromise (Himmelmann, Beckung, Hagberg,
& Uvebrant, 2007; Krägeloh-Mann & Cans, 2009). Oro-
pharyngeal swallowing is a complex sensorimotor function
controlled by a network of peripheral and central neural
mechanisms that involve both hemispheres and bilateral
control of the head and neck (Malandraki, Sutton, Perlman,
Karampinos, & Conway, 2009). We recently showed pre-
liminary evidence suggesting that children with unilateral
early brain lesions may be able to use recovery mechanisms
of the contralesional hemisphere to develop their swallowing
skills (Mourao et al., 2017). Studies focusing on motor
hand control in children with USCP have also shown that
the contralesional hemisphere possesses substantial compen-
satory potential for motor function recovery (Staudt, 2007).
These recovery mechanisms may not be as widely available
in children with bilateral and more systemic brain lesions,
and further investigation of these differential neuroplastic
mechanisms is warranted.
Mishra et al.: Mealtime Duration in Cerebral Palsy 105
 Limitations
This investigation was not without limitations. We
acknowledge that our sample size was small and resulted
in limited power that necessitated the use of nonparametric
statistics. In addition, our participants represented a con-
venience sample of self-feeding children who were main-
streamed in school and had no significant intellectual
disability or other comorbidities. Future studies should
incorporate larger sample sizes with a wider representation
of children with CP across levels of motor impairment to
allow for greater generalization of results. In addition, we
did not control the types of foods/liquids provided to each
child, as children consumed foods/liquids that were repre-
sentative of their daily mealtime routine. In doing so, we
aimed to capture duration aspects of a natural meal, thus
increasing the ecological validity of the study. Although
use of the natural meal is consistent with the validation of
the DDS (Sheppard et al., 2014), we do acknowledge that
standardization of food types would have allowed for deeper
interpretations of the findings and should be explored in
the future.
Assessment of duration measures was based on video
analysis for increased accuracy and feasibility of the indi-
vidual sip/bite durations’ calculations. Examining the reli-
ability of these measurements in live clinical evaluations
needs to also be investigated. Assessment of feeding and
swallowing performance was based on a standardized clinical
assessment tool (DDS). At the time of the study, we did
not have access to videofluoroscopy (videofluroscopic
swallowing study) or pediatric fiberoptic endoscopic evalu-
ation of swallowing. In pediatrics, however, it has to be
noted that instrumental assessments are not always needed
or indicated (Arvedson, 2008). In this study, it would be
unethical to expose children to ionizing radiation (video-
fluoroscopy), or invasive evaluations (endoscopy), because
they did not present with significant medical history or
signs of aspiration that would necessitate an instrumental
assessment. In addition, the DDS is a standardized tool
that has been used by several researchers to screen/evaluate
feeding and swallowing performance in children with CP
(Benfer et al., 2013; Calis et al., 2008; Kantarcigil et al.,
2016; Sheppard et al., 2014).
Conclusions
We developed objective and clinically practical mea-
sures of mealtime duration and subcomponents, which
were shown to be highly reliable. Our preliminary results
further show that these measures are associated with clinical
signs of feeding and swallowing difficulties in our cohort
of school-aged, self-feeding children with CP. With the
limited availability of objective, noninvasive, and validated
tools for the assessment of pediatric dysphagia, the develop-
ment of these measures can offer a useful and objective
supplemental tool to the clinical feeding and swallowing
assessments for this population. While the present investi-
gation provides valuable preliminary data, further research
106 American Journal of Speech-Language Pathology • Vol. 27 • 99–107 • February 2018
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is warranted to determine the validity of these measures
in a larger and more representative sample of children
with CP.
Acknowledgments
This study was partially supported by internal funds provided to
Georgia A. Malandraki by Teachers College, Columbia University,
and Purdue University. The authors thank the children and their
parents for their participation. We also acknowledge with grati-
tude the contributions of Erika Levy for her help with subject
recruitment; Akila Rajappa, Chad Grossman, Kamila Kaldan,
Manushree Karthik, Aditi Valada, and Lucia Mourao for their
help with data collection; and Alyssa Jones and Katy Baar for
their help with data analysis.
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