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Development and Content Validation of the Pediatric Eating Assessment Tool

(Pedi-EAT)

Article  in  American Journal of Speech-Language Pathology · October 2013

DOI: 10.1044/1058-0360(2013/12-0069) · Source: PubMed

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 AJSLP
Research Article
Development and Content Validation
of the Pediatric Eating Assessment
Tool (Pedi-EAT)
Suzanne M. Thoyre,a Britt F. Pados,a Jinhee Park,a Hayley Estrem,a Eric A. Hodges,a
Cara McComish,a Marcia Van Riper,a and Kimberly Murdochb
Purpose: In this article, the authors describe the
development and content validation of a parent-report
measure of problematic eating behaviors: the Pediatric
Eating Assessment Tool (Pedi-EAT).
Method: In Phase I, items were generated from parents’
descriptions of problematic feeding behaviors of children,
review of literature, and review of existing eating-related
instruments. In Phase II, interdisciplinary experts on pediatric
eating behaviors rated the items for clarity and relevance
using content validity indices (CVI) and provided feedback
on the comprehensiveness of the instrument. In Phases III
and IV, 2 groups of parents of children with and without
feeding difficulties participated in cognitive interviews to
gain respondent feedback on content, format, and item
interpretation. The authors analyzed interviews using matrix
display strategies.
T
he eating behaviors children express reflect
codependent interactions among intrinsic properties
of the child, the environment, and dimensions of
the task itself (Thelen & Smith, 1994). Problematic eating
behaviors, such as refusal of specific or all foods, gagging
during mealtime or in anticipation of eating, avoidance of
specific food textures, or insistence on food being offered in a
certain way, pose significant challenges for children, families,
and health care providers (Arvedson, 2008; Linscheid, 2006;
Stoner, Bailey, Angell, Robbins, & Polewski, 2006). As
problematic behaviors repeat over time, they can become
entrenched and difficult to change, and nutrition and growth
often suffer (Williams, Riegel, & Kerwin, 2009). Families
report it can be difficult to gain a clinician’s agreement that a
a
The University of North Carolina at Chapel Hill
b
Cheshire Speech and Voice Center, Raleigh, NC
Correspondence to Suzanne Thoyre: thoyre@email.unc.edu
Editor: Carol Scheffner Hammer
Associate Editor: Jane Mertz Garcia
Received July 22, 2012
Revision received January 10, 2013
Accepted June 29, 2013
DOI: 10.1044/1058-0360(2013/12-0069)
American Journal of Speech-Language Pathology • 1–14 • A American Speech-Language-Hearing Association
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Results: Experts rated the total scale CVI > .90 for both
relevance and clarity; item CVI ranged from .67 to 1.0 for
relevance and .5 to 1.0 for clarity. Analysis of each item
with low scores, along with experts’ and parents’ feedback,
resulted in refinement of the items, scoring options, and
directions. Experts and parents added additional items.
Readability after refinements was acceptable at less than
a 5th-grade level.
Conclusion: The Pedi-EAT was systematically developed
and content validated with input from researchers, clinicians,
and parents.
Key Words: eating behavior, content validity, parent report,
instrument development, cognitive interviews, feeding
difficulty
problem exists (Rogers, Magill-Evans, & Rempel, 2012;
Thoyre & Van Riper, 2010), and clinicians are often faced
with a problem that may be difficult to differentiate from
typical behavior of children (Kerzner, 2009). Comprehensive
measurement of eating behaviors is a necessary component
of the diagnostic process (Williams et al., 2009) and critical
to moving clinical care and empirical study of childhood
eating problems forward.
In this article, we describe the conceptual framework
and development of a new instrument, the Pediatric Eating
Assessment Tool (Pedi-EAT). We present content validity
testing of the instrument by two methods: (a) testing of the
relevance and clarity of items and comprehensiveness of the
Pedi-EAT by interdisciplinary clinical and research experts and
(b) content validation by parents of children with and with-
out feeding difficulty using cognitive interviews. We present
readability testing and plans for further psychometric testing.
Background and Conceptual Framework
Many families seek assistance in solving feeding issues
of their young children. Recent published estimates indicate
Disclosure: The authors have declared that no competing interests existed at the
time of publication.
1
 approximately 20% of families of typically developing
children have feeding concerns (Mascola, Bryson, &
Agras, 2010; Wright, Parkinson, Shipton, & Drewett, 2007).
This number increases to as high as 80% when children have
developmental disabilities (Gal, Hardal-Nasser, & Engel-
Yeger, 2011; Sullivan et al., 2000), such as autism (Emond,
Emmett, Steer, & Golding, 2010; Martins, Young, & Robson,
2008; Rogers et al., 2012) or cerebral palsy (Erkin, Culha,
Ozel, & Kirbiyik, 2010; Wilson & Hustad, 2009). Feeding
difficulties are common among children with genetic disorders
(Cooper-Brown et al., 2008; Dobbelsteyn, Peacocke, Blake,
Crist, & Rashid, 2008) and multiple medical conditions,
such as past history of prematurity (DeMauro, Patel, Medoff-
Cooper, Posencheg, & Abbasi, 2011; Samara, Johnson,
Lamberts, Marlow, & Wolke, 2010; Törölä, Lehtihalmes,
Yliherva, & Olsén, 2012), congenital heart disease (Medoff-
Cooper, Naim, Torowicz, & Mott, 2010), gastrointestinal
problems (Wu, Franciosi, Rothenberg, & Hommel, 2012),
cystic fibrosis (Sheehan et al., 2012), and Type 1 diabetes
(Patton, Williams, Dolan, Chen, & Powers, 2009).
In all feeding difficulties, the specific eating behaviors
exhibited are central features of the problem (Williams et al.,
2009). A wide range of eating behaviors can be exhibited,
even within the same condition; and many conditions share
the same problematic behaviors (Berlin, Lobato, Pinkos,
Cerezo, & LeLeiko, 2011). Broad categorization or clas-
sification of a feeding problem, such as “food refusal,” can
have multiple etiologies (Berlin et al., 2011; Bryant-Waugh,
Markham, Kreipe, & Walsh, 2010) and therefore offers
limited diagnostic value. Alternatively, thorough descrip-
tion of problematic behaviors provides the basis for deter-
mining the most likely etiology of the problem and is
essential for the development of targeted and effective
interventions. A means of measuring these behaviors is
therefore essential.
Dynamic systems theory guides our understanding
of the development of eating behaviors during childhood
(Thelen & Smith, 1994). Problematic behaviors are viewed
as an emergent property of the continuous interaction of
multiple subsystems within the child, the environment, and
features of the task itself. Because subsystems are dynamic,
interacting, and changing as the result of development,
learning, experience, and health, the expression of problem-
atic eating behaviors may change over time (Davids, Button,
& Bennett, 2008; Rogers et al., 2012; Rommel, De Meyer,
Feenstra, & Veereman-Wauters, 2003). Furthermore, per-
formance capacities intrinsic to children constrain or shape
the possibilities of their eating behavior (Davids et al., 2008;
Humphry, 2002). Capacities include neurological, oral motor,
and gross and fine motor development; sensory regulation;
cognitive abilities; and health, including cardiac, gastro-
intestinal, metabolic, and respiratory functioning. Some con-
straints will more strongly restrict behavior than others. For
example, children with cardiac disease who have limited
energy for exercise may take a long time to eat (Medoff-
Cooper et al., 2010) or require shorter, more frequent feedings
(Hartman & Medoff-Cooper, 2012). Limited energy reserves,
in this case, can be a rate-limiting constraint on eating.
2 American Journal of Speech-Language Pathology • 1–14
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Eating behaviors develop within a complex system that
is self-organizing and drawn to stable states through pattern
formation when emergent behaviors achieve intended out-
comes (Humphry, 2002; Thelen, 2005) and as neuronal con-
nections become more defined and preferred (Knudsen, 2004).
Eating behaviors therefore reflect capacities and the patterns
of behavioral organization that have become familiar and
successful. Previous experiences with food and mealtime,
surrounded by performance-limiting capacities, and specific
environmental and task constraints drive the behaviors that
emerge. For example, children who have difficulty chewing
have several behavioral options when foods that require
chewing are offered. They may refuse the food, swallow the
food without adequately chewing, expel or spit the food out,
or soften the food by sucking on or storing it in the cheek
or roof of mouth (Morris & Klein, 2000). Each of these
behaviors, however different, can reflect difficulty chewing.
Which behavior emerges is a function of multiple factors:
the behavior’s stability given the specific current constraints,
the behavioral solutions perceived to be effective based on
past success, and the behavioral patterns that have become
strengthened over time.
An adequate measure of problematic eating behaviors
needs to include the wide range of behaviors that children
may exhibit and be applicable to the measure’s various
intended functions, including clinical assessment, family-
provider communication, and research.
Measurement of Problematic Eating Behaviors
in Children
Given the variety of intended functions and users of a
measure of problematic eating behaviors, several features are
important to consider. Direct observation of the child or
report by a valid observer, with an aim to identify the range
of behaviors children exhibit, is essential. In addition, the
measurement method needs to be clinically useful, family-
friendly, and psychometrically sound. Finally, the method
needs to support repeated measurement to evaluate change
over time, response to treatment, and yield quick results with
minimal time and cost.
Measurement of behavior can be accomplished through
systematic observation, using reliable coding schemes or
rating scales with trained observers, or through report by
an observer who is directly involved in feeding the child on
a regular basis, such as a parent. Systematic observation
has psychometric strength; however, capturing a full descrip-
tion of problematic eating behaviors may require repeated
observations over a period of time and across settings (Piazza-
Waggoner, Driscoll, Gilman, & Powers, 2008; Young &
Drewett, 2000). This presents time and cost burdens and
diminishes the usefulness of systematic observation for
frequent assessment. Moreover, the lag between systematic
observation and the availability of a resulting report would
limit clinical utility. Alternatively, in clinical settings, practi-
tioners often adopt a homegrown and untested method for
observing and describing problematic eating behaviors using
a checklist and/or interview schedule. Although these tools
 have some clinical utility, they lack the psychometric testing
needed for research use or widespread acceptance.
Parent report of the child’s problematic eating be-
haviors has several advantages. Parents are more likely than
an outside observer to be able to report frequency of a wider
range of eating behaviors that occur across the settings the
child naturally encounters. As an example, Piazza-Waggoner
et al. (2008) compared the agreement between parent report
of child mealtime behaviors with systematic observation of
those behaviors during an average of three meals observed
in the child’s home. There was significant agreement between
the two observation methods for some behaviors (e.g., length
of meal or child leaving table) but little agreement for others
(e.g., whines, cries, or tantrums at feeding time or refuses to
eat meals but requests food immediately after the meal ). Some
behaviors are not elicited with every instance of eating, and
the child’s behavior may be altered by unfamiliar mealtime
settings and/or unfamiliar observers (Haidet, Tate, Divirgilio-
Thomas, Kolanowski, & Happ, 2009). Because parent-
report measures are relatively inexpensive and place minimal
burden on the family, they permit frequent measurement,
making them ideal for tracking the development of eating
problems and response to feeding interventions over time.
In addition, results of parent-report measures have the
potential for immediately available results, which further
strengthens their utility.
Parent-report instruments, however, are not without
limitations. They are a measure of parents’ perception of
their child’s behavior, and this comes with inherent bias
that needs to be considered in the construction of the in-
strument and during interpretation of results. Parents may
be motivated to magnify problematic behaviors to gain a
clinician’s attention. In contrast, they may underreport the
frequency of behaviors that they have become accustomed
to. Although parent-report scales have been found to be
a valid means of measuring early child communication skills
(Määttä, Laakso, Tolvanen, Ahonen, & Aro, 2012) and
behaviors representing developmental risk (Martin et al.,
2012), others note minimal congruence between teachers and
parents or clinicians and parents when rating behavioral
problems (De Los Reyes & Kazdin, 2005). There is no
definitive way to judge which reporter is able to provide a
more accurate measure of behavior because there is no gold
standard for identifying problematic behaviors. Different
reporters may have different interpretations and definitions
of what constitutes “problematic” (Dirks, De Los Reyes,
Briggs-Gowan, Cella, & Wakschlag, 2012). Given their
utility yet potential for bias, it is essential that parent-report
measures be designed to minimize error and have high
content validity (DeVellis, 2012; Drennan, 2003).
Evaluation of the Content Validity
of Available Instruments
Content validity is defined as the degree of confidence
that the instrument’s items adequately represent the con-
struct being measured and that all elements of the instrument
(directions, response options, and items) are relevant and
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clear (DeVellis, 2012). As such, content validity focuses on
the strength of the instrument itself and is the first step in
instrument development (DeVellis, 2012). Content validity is
accomplished through a multistage, quantitative, and qual-
itative process, including (a) instrument development that
includes domain identification and item generation repre-
sentative of the identified domains of the construct being
measured (DeVellis, 2012; Lynn, 1986); (b) a quantified
evaluation of the instrument’s content by experts in the field
(Lynn, 1986); and (c) systematic qualitative review of the
instrument for clarity, relevance, and completeness by the
intended respondents (Willis, 2005).
We evaluated the strength of the content validity of
eight available parent-report instruments that measure
problematic eating behaviors of children (see Table 1).
Although all eight instruments included items related to
the construct of problematic eating behaviors, several of
the instruments mixed constructs such as parent feeding
strategies, parent feelings, or family mealtime interactions.
This makes the operationalization of problematic eating
behaviors imprecise and the ability to isolate the frequency
and severity of the child’s eating behaviors difficult. One
instrument is designed for use with children with autism
(Brief Autism Mealtime Behavior Inventory [BAMBI];
Lukens & Linscheid, 2008), thus limiting its use to a narrow
audience. Although some of the instruments were specifi-
cally designed to be brief, none of the instruments measure
the range of problematic eating behaviors families have
reported (e.g., Marquenie, Rodger, Mangohig, & Cronin,
2011; Thoyre & Van Riper, 2010).
Items on the reviewed instruments were derived from
clinical experience, studies reported in the literature at the
time of their development, and through a process of bor-
rowing from prior instruments addressing children’s eating
behaviors. Although these are excellent sources for item
generation, none of the instruments generated items from
parent interviews. Because parents are the intended re-
spondents of the instrument, these instruments’ items may
lack parents’ perspectives and the language parents typically
use.
Finally, only one of the instruments (BAMBI)
reported any assessment of content validity. Items of the
BAMBI were reviewed by clinical experts; however, no
standardized process for this review was reported (Lukens &
Linscheid, 2008). When the Screening Tool of Feeding
Problems Applied to Children (STEP-CHILD; Seiverling,
Hendy, & Williams, 2011) was adapted from the STEP, no
content validity assessment was reported, although the
original STEP for adults was judged by clinical experts for
comprehensiveness and appropriateness (Matson & Kuhn,
2001). Neither the BAMBI nor the STEP-CHILD had
quantified content expert assessments; thus, they do not meet
the standards set for content validity testing and may, more
accurately, be referred to as having face validity (Lynn,
1986). Of all available instruments, none were developed
with both quantified expert and qualitative parent evaluation
of content validity. The available instruments therefore do
not meet standards for content validity for research purposes
Thoyre et al.: Pediatric Eating Assessment Tool 3
 4 American Journal of Speech-Language Pathology • 1–14

Table 1. Review of existing parent-report pediatric eating behavior instruments and content validation procedures.

Item generation Content validity testing

Review Adaptation Quantified Qualitative
Instrument name Construct(s) Content Parent Literature of existing of existing Review by evaluation review by
(author) of interest Item content experts interview review instrument(s) instrument experts by experts parents

Children’s Eating Eating and mealtime Child: Food preferences, X X

Behavior Inventory problems: child, motor skills, behavioral
(Archer et al., 1991) parent, and family compliance (28 items)
domains Parent/family system:
Child behavioral
controls, cognitions
and feelings about
feeding, impact on
family members,
mutuality between
family members,
family mealtime
interactions (12 items)
Behavioral Pediatrics Child behaviors Child: mealtime behaviors, X X
Feeding Assessment associated with restrictiveness of diet
Scale—Child poor nutritional (25 items)
Behaviors subscale intake: child
(Crist et al., 1994) domains
Pediatric Assessment Severity of feeding Description of reliance X X
Scale for Severe difficulty when on tube (2 items);
Feeding Problems also tube-fed: eating behaviors
(Crist et al., 2004) child and parent (8 items); quality of
domains life for child/parent
(4 items); acceptance
of food texture and
temperature (9 items)
About Your Child’s Behavioral and [Factor-derived] resistance X X
Eating—Revised parent–child to eating (parent and
(Davies et al., 2007) interactional child, 11 items),
mealtime positive mealtime
difficulties environment (5 items),
and parent aversion
to mealtime (4 items)
Brief Autism Mealtime Mealtime behavior [Factor-derived] limited X X X
Behavior Inventory problems in variety (8 items),
(BAMBI; Lukens & children with food refusal (5 items),
Linscheid, 2008) autism features of autism
(5 items)

(table continues)

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 Table 1 (Continued).

Item generation Content validity testing

Review Adaptation Quantified Qualitative
Instrument name Construct(s) Content Parent Literature of existing of existing Review by evaluation review by
(author) of interest Item content experts interview review instrument(s) instrument experts by experts parents

Mealtime Behavior Mealtime behavior [Factor-derived] food X

Questionnaire problems refusal/avoidance
(Berlin et al., (12 items), food
2010) manipulation (7 items),
mealtime aggression/
distress (9 items), and
choking/ gagging/
vomiting (3 items)
Montreal Children’s Feeding problems Oral motor, oral sensory, X
Hospital Feeding in children appetite, maternal
Scale (Ramsay et al., concerns, mealtime
2011) behaviors, maternal
strategies, family
reactions (14 items)
Screening Tool of Child feeding [Factor-derived] X X
Feeding Problems behavior chewing problems
Thoyre et al.: Pediatric Eating Assessment Tool

Applied to Children problems (3 items), rapid eating

(STEP-CHILD; (3 items), food refusal
Seiverling et al., (3 items), food selectivity
2011) (2 items), vomiting
(2 items), stealing food
(2 items)

Note. Data are presented for revised tool versions when available.
5

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 (Knafl et al., 2007; Lynn, 1986). Although the instruments
may demonstrate reliability, we cannot know with certainty
the degree to which the items are relevant, clear, and rep-
resentative of the construct. Furthermore, whether parents
interpret the items as intended and find the instruments to be
clear and comprehensive have not been reported.
Method
Based on DeVellis’ (2003) guidelines for scale devel-
opment, development of the Pedi-EAT was conducted in
four phases, with readability adjustments made before and
after each phase of validation by parents, as illustrated in
Figure 1.
Phase I: Item Generation
The Pedi-EAT was designed to be a comprehensive
parent-report measure of eating behaviors parents may
observe with their children—both positive (e.g., enjoys eating,
acts hungry before meals, is willing to feed him- or herself ) and
problematic (e.g., eats too fast, breathes faster or harder when
Figure 1. Phases of development of the Pedi-EAT. aVan Riper & Thoyre, 2006.
6 American Journal of Speech-Language Pathology • 1–14
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eating, gags with foods that need to be chewed ). Items were
selected to capture the range of eating-related behaviors
observed in children ages 6 months and older and currently
being offered solid food (nonliquids), as recommended by the
American Academy of Pediatrics (Eidelman et al., 2012), with
acknowledgment that some behaviors will not be relevant
at all ages. Items were selected from three sources: (a) an
available set of interviews with parents of children with a wide
range of feeding problems, which included descriptions of
their child’s eating behaviors; (b) literature descriptions of
problematic eating behaviors during childhood at the time
of item generation; (c) and examination of the eating
behavior items of available instruments.
Secondary analysis of focus groups and individual
interviews conducted by Thoyre and Van Riper (2010)
provided input about problematic eating behaviors as
described by parents of children with Down syndrome.
Children with Down syndrome, as in most conditions with
associated comorbidities, display a range of feeding diffi-
culties (Van Riper & Thoyre, 2006). Thoyre and colleagues
recruited participants in three states (North Carolina, Ohio,
and Utah) through support groups, pediatric specialty
clinics, and word-of-mouth. Focus groups averaged four
 participants per group. Prior to the interview, participants
were asked to subjectively assess whether their child had any
feeding difficulties, and if “yes,” to rate severity on a scale
of none, mild, moderate, or severe.
Additional items for the Pedi-EAT were generated
from a review of English language literature and examina-
tion of existing measures of problematic eating behaviors of
children. We searched PubMed and CINAHL databases
for feeding and eating behaviors of children at high risk for
feeding problems, including, but not limited to, children
with congenital heart disease, Down syndrome, prematurity,
autism spectrum disorder, and cerebral palsy. We then
performed a content analysis of descriptive clinical articles
(e.g., Cooper-Brown et al., 2008; Hyman, 1994; Mason,
Harris, & Blissett, 2005; Norris & Hill, 1994), research
reports (e.g., Carruth & Skinner, 2002; Mercado-Deane et al.,
2001), and books (e.g., Kedesdy & Budd, 1998; Morris &
Klein, 2000), looking specifically for normal and abnormal
behaviors related to eating. The following instruments ad-
dressing childhood eating behaviors available at the time of
item development were reviewed: Children’s Eating Behavior
Questionnaire (Wardle, Guthrie, Sanderson, & Rapoport,
2001), Behavioral Pediatrics Feeding Assessment Scale—
Child Behaviors subscale (Crist et al., 1994), Pediatric
Assessment Scale for Severe Feeding Problems (Crist,
Dobbelsteyn, Brousseau, & Napier-Phillips, 2004), Children’s
Eating Behavior Inventory (Archer, Rosenbaum, & Streiner,
1991), BAMBI (Lukens & Linscheid, 2008), About Your
Child’s Eating—Revised ( Davies, Ackerman, Davies,
Vannatta, & Noll, 2007), and the Behavioral Assessment
Scale of Oral Functions in Feeding (Stratton, 1981).
Phase II: Content Validity Testing by
Interdisciplinary Clinical and Research Experts
The second phase of instrument development involved
validation of the Pedi-EAT content by professionals with
expertise in pediatric eating behaviors. A panel of 18 clinical
and research content experts from four countries represent-
ing a range of disciplines, including psychology, speech-
language pathology, nutrition, and occupational science,
were invited to review the Pedi-EAT for relevance and clarity
of the items and comprehensiveness of the instrument.
Although the content experts were cross-disciplinary, the
majority of the invited participants were speech-language
pathologists. Experts were selected on the basis of history of
publication, presentations, and research and /or clinical
expertise.
We sent invitations to participate via e-mail; the
messages contained an attached file of the Pedi-EAT, a
description of the instrument’s purpose, and a link to an
online survey. Survey responses were received anonymously;
we did not request demographic data about the respondents.
A reminder email was sent 1 month following the initial
invitation. Once initiated, the survey directed the participant
to examine each item of the Pedi-EAT and provide two
ratings, one for the item’s relevance, and a second for the
item’s clarity, using 4-point ordinal scales (1 indicating
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no relevance/clarity, 4 indicating high relevance/clarity).
Participants were given the opportunity to provide feedback
on the wording of items and to suggest additional items.
Content validity indices (CVIs) were calculated at both
the item level (I-CVI) and at the scale level (S-CVI) for
both relevance and clarity (Lynn, 1986; Polit & Beck, 2006).
For each item, an I-CVI for relevance was calculated as the
proportion of content experts who rated the item moder-
ately or highly relevant (Polit & Beck, 2006). An I-CVI for
clarity was calculated using the same process. The S-CVI
was calculated as the average of the I-CVIs for all of the
items on the scale (Polit & Beck, 2006). Acceptable limits
for I-CVIs and for the S-CVI are dependent on the number
of content experts surveyed. With more than six experts, the
minimum acceptable I-CVI is .78 (Lynn, 1986). An I-CVI
of less than .78 indicates that the item is either irrelevant or
unclear and changes need to be made to remove the item,
make the item more relevant, or improve clarity. At the
scale level, with more than six experts, the acceptable S-CVI
is .90 or higher (Polit & Beck, 2006).
Five of the Pedi-EAT investigators conducted sys-
tematic item-by-item analysis of expert ratings and feedback.
They made decisions to eliminate or revise items, separate an
item into two or more items, retain an item unchanged, or
add suggested items.
Phase III: Content Validation by Parents of Children
With Feeding Difficulty
The third phase of instrument development involved
establishing content validity of the Pedi-EAT by the target
respondents of the instrument—that is, parents of children
with feeding difficulties. Cognitive interviewing, a widely
used technique to learn how respondents of questionnaires
process and respond to items, was used in this phase
(Drennan, 2003; Knafl et al., 2007; Willis, 2005).
Parents who identified having a child over the age of
6 months with feeding difficulty were recruited from a feeding
disorders clinic, several websites for parents of children with
disabilities, and by word of mouth. Once parents consented,
we arranged an interview of approximately 1 hr in length.
Parents completed a demographic questionnaire. During the
interview, each item of the Pedi-EAT was read aloud, and
parents were asked to state their interpretation of the meaning
of the item. Parents were also asked whether the directions
were clear, if the response options were understandable, and
how easy or difficult they thought it would be to complete
the Pedi-EAT. Verbal probing was used to clarify responses
(Willis, 2005). Finally, parents were invited to share sug-
gestions for improving the instrument, including additional
items that would better capture behaviors seen in their own
child. No compensation for participating was provided.
All interviews were audio-recorded and summarized in
a matrix format. Prior to analysis, a second team member
verified the transcribed data by listening to the interview
recording. Five of the Pedi-EAT investigators conducted
systematic column-by-column analysis (Miles & Huberman,
1994). Problem categories, such as “unclear meaning” and
Thoyre et al.: Pediatric Eating Assessment Tool 7
 “redundancy” were created based on parent feedback (Knafl
et al., 2007). Decisions were made by the team to retain
an item unchanged, revise, delete, split an item into two,
or add an item.
Phase IV: Content Validation by Parents of Children
With and Without Feeding Difficulty
After analysis of the Phase III cognitive interviews,
it became clear that a second round of cognitive interviews
was needed. The comprehensiveness and interpretation of
the newly revised items needed to be evaluated, and infor-
mation was needed on parents’ experience of completing the
instrument. In addition, because the instrument may be used
with parents of children with and without feeding difficulty,
it was necessary to assess whether parents of children without
feeding difficulty understood the items in the same way as did
parents of children with feeding difficulty.
We recruited parents of children over the age of
6 months who were orally feeding at least some solid foods.
Parents self-identified whether their child had feeding dif-
ficulty (yes/no); no clinical diagnosis was required. We aimed
to have an equal balance of parents of children with and
without feeding difficulty represented in the sample. Invita-
tions to participate were posted on local parenting Listservs,
including parent-run support groups for families with children
with conditions that often include feeding challenges. Re-
cruitment also involved participant word of mouth. Efforts
were made to increase the income range and diversity of the
subjects compared with the Phase III cognitive interviews
by posting invitations to participate in targeted public loca-
tions and a feeding disorders clinic.
As in the Phase III of cognitive interviews, once
parents consented, we arranged an interview of approxi-
mately 1 hr in length. No compensation for participating
was provided. Prior to the interview, parents were asked to
complete the Pedi-EAT, note the length of time for com-
pletion, and indicate items needing clarification. During the
interview, we again used verbal probing to elicit information
about the ease of completing the questionnaire, the clarity
of the directions, and appropriateness of response options
(Willis, 2005). Items that were changed after the Phase III
cognitive interviews were then reviewed, and participants
were asked to provide their interpretation of the items’
meaning. Probes were used to clarify parents’ responses.
Again, parents were invited to share any additional thoughts
and suggest additional items. As in Phase III, the interviews
were digitally audio-recorded, summarized into a matrix
format by the interviewer, and verified by a second team
member using the audio recording. Seven of the Pedi-EAT
investigators replicated the analytic procedures from the
Phase III cognitive interviews (Miles & Huberman, 1994).
Results
Phase I: Item Generation
Thirty-seven caregivers of children with Down syn-
drome (33 mothers, 3 fathers, and 1 care provider) participated
in the focus group or individual interviews (see Table 2), as
described by Thoyre and Van Riper (2010). Participants
reported that the target child (ages 9 months through 13 years)
had an average of 5 (range 1–13) eating behaviors that were
challenging. Two children were reported to have severe
feeding difficulty, 32 had moderate difficulty, and 3 had no
or mild feeding difficulty. Thirty-four participants expressed
concern that the child was underweight, and 29% were
offering enhanced calorie formula. The most commonly
reported difficulties were selectivity about types of foods
eaten, delayed initiation of chewing or difficulty with chewing,
avoidance of textured foods mixed with smooth foods, lack
of interest in eating, difficulty swallowing, selectivity about

Table 2. Demographics of samples by phase of development.

Phase IV cognitive interviews

Phase I item generation Phase III cognitive interviews: No feeding difficulty Feeding difficulty
Variable interviewsa ( n = 37) feeding difficulty ( n = 9) ( n = 10) ( n = 10)

Mean age of child in 2.7 (0.8–13) 4.3 (0.8–10.1) 4.1 (1.6–7.8) 4.8 (1.4–9.7)
years (range)
Difficulty breast or 59% 100% 30% 40%
bottle-feeding
Current tube feeding 5% 55% 0% 0%
Race/ethnicity of child
White 92% 77% 50% 90%
African American 5% 11% 30% 0%
Self-defined 3% African / Native American 11% African / Native American 20% White/ Hispanic 10% White/ Brazilian
Mean family income > $60 (< $20 to > $60) $70–$80 ($30 to > $100) $50–$60 (< $20 to > $100) $70–$80 ($20 to > $100)
(range)b
Family type: 94% 88% 100% 90%
Two-parentc

Note. Phase I = item generation; Phase III = content validation by parents of children with feeding difficulty; Phase IV = content validation by
parents of children with and without feeding difficulty. aVan Riper & Thoyre, 2006. bIncome in thousands of dollars; the upper limit the parent could
select was > $60,000 in Phase 1 and > $100,000 in the remaining three samples. cIncludes step-parent and same-sex parents.

8 American Journal of Speech-Language Pathology • 1–14

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 how foods are offered, delayed skill development, and
spitting up.
A list of 44 items was generated from the interviews.
We added 39 additional items from the literature review and
25 items from the review of existing instruments for a total
of 108 items. All items were written to be concise and to
begin with the phrase “My childI .” We avoided language
of interpretation; respondents reported observable behaviors
rather than the meaning of the behavior, their perception of
the child’s intentions, or their interpretation of the etiology
of the behavior. For example, an item may state “my child
stops eating after a few bites ” rather than “my child seems
to get full before eating enough.” Approximately half of
the items are worded positively and half negatively. The
response format began as a five-point balanced response
scale with the following options: never, almost never, some-
times, often, and almost always. Directions at the beginning
of the instrument asked parents to think back over a typical
2-week period and to check the response that best described
their child. The research team chose the 2-week time frame
to be large enough to detect the frequency of current
behaviors yet small enough to facilitate accurate parent
recall and enable the instrument to be used for repeated
measurements of progress over time.
Phase II: Content Validity Testing by
Interdisciplinary Clinical and Research Experts
Thirteen of the 18 invited experts provided feedback
on the Pedi-EAT. Nine participated in the content validity
survey, and four provided written feedback only. Ratings
for item clarity were omitted by one respondent; therefore,
content relevance of each item was rated by nine experts, and
the clarity of each item was rated by eight.
The I-CVIs for relevance ranged from .67 to 1.0, and
the I-CVIs for clarity ranged from .50 to 1.0. Thirty items
Table 3. Examples of eliminated, reworded, separated, and retained items.
I-CVI
Decision Sample items Relevance
Eliminated My child wants to eat. .75
My child sighs during mealtime. .63
My child can drink from a straw. .89
Reworded My child drinks between mouthfuls. .67
My child is particular about how food 1.00
is offered.
My child over-fills his/her mouth. .78
Separated My child spills food or liquid out of mouth 1.00
while eating.
My child will eat warm or cold food. .89
Retained My child will touch food with his/her hands. .67
My child pauses in the middle of eating to .75
take a rest.
Note. I-CVI = Item Content Validity Index.
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(28%) did not meet the criteria of .78 for relevance and /or
clarity (Lynn, 1986). The S-CVI was acceptable for both
relevance (.93) and clarity (.90; Polit & Beck, 2006). Table 3
provides examples of items rated as having low relevance
and /or clarity and illustrates the decisions and rationale for
the item’s management.
Of the 30 items with low I-CVI scores, five had both
low relevance and low clarity, five had low relevance, and
20 had low clarity. Item-by-item analysis of problematic
items and expert feedback (both on the survey and written)
resulted in the following decisions. Seventeen items were
eliminated due to low relevance or redundancy. Eleven
additional items were determined to be inconsistent with the
conceptual purpose of the Pedi-EAT and were eliminated.
Five of these items asked parents to interpret what their
children were capable of doing (e.g., can drink from a straw,
is able to sit up without support during feeding), and six items
described the adequacy of diet (e.g., my child eats foods with
protein [beans, cheese, meat, fish]). A total of 39 items were
revised to improve clarity or grammar. Three items were de-
termined to be measuring two behaviors each; therefore, they
were each split into two items. Four new suggested items
were added. The revised Pedi-EAT consisted of 87 items.
Phase III: Content Validation by Parents of Children
With Feeding Difficulty
Nine parents of children between the ages of 9 months
and 10 years with feeding difficulty participated in the
Phase III cognitive interviews. See Table 2 for demographics
of the sample. Over half were caring for children with an
enteral feeding tube, and all reported an early origin of their
child’s feeding problems.
Column-by-column analysis of the summarized
data from the cognitive interviews led to the revision of
33 items; elimination of four items; and, in response to
Clarity Rationale or revision
.86 Low I-CVI for relevance and redundant with other items.
.71 Low I-CVI (both for relevance and clarity).
1.00 Represents a skill rather than an eating behavior.
.75 My child needs to take a drink between mouthfuls.
.50 My child insists on food being offered in a certain way
(such as how food is arranged on the plate or what
dishes or spoon or fork is used).
.88 My child puts too much food in at one time.
1.00 My child spills food out of mouth while eating.
My child spills liquid out of mouth while eating.
.50 My child eats warmed food.
My child eats cold food.
.75 Critical eating behavior described in the literature related
to sensory modulation disorders.
1.00 Critical eating behavior described in the literature related
to physiologic functioning.
Thoyre et al.: Pediatric Eating Assessment Tool 9
 parents’ suggestions and new literature, the addition of
12 items. Fifty items were interpreted by parents as intended
and therefore were retained without modification. Parents
commented that the Pedi-EAT was straightforward and
reasonable in length. The PediEAT was found to be of
limited use for children who were not eating at least some
solid foods. The directions for completion of the Pedi-EAT
were revised to improve clarity, and the resulting Pedi-EAT
consisted of 95 items.
Phase IV: Content Validation by Parents of Children
With and Without Feeding Difficulty
Twenty parents of children between the ages of
17 months and 10 years participated in the Phase IV
cognitive interviews. Half of the parents identified their
children as having feeding difficulties. Compared with
Phase III, participants in Phase IV were slightly more
diverse in both income and race/ethnicity (see Table 2).
Phase IV led to the revision of seven items, abbrevi-
ation of 38 items, elimination of three items, and the addition
of five items. The resulting Pedi-EAT consisted of 97 items.
The directions were further revised to focus parents on
reporting their children’s typical, current behavior. Parents’
postcompletion feedback resulted in our changing the re-
sponse format to a six-point balanced response scale with
the following options: never, almost never, sometimes, often,
almost always, and always. Parents of children without
feeding difficulty were less familiar with descriptions of prob-
lematic eating behaviors; we revised several items based on
this feedback. The average length of time to complete the
Pedi-EAT for these 20 parents was 16 min. Figure 2 illustrates
the format of the final Pedi-EAT.
Readability Testing
Readability of the Pedi-EAT was tested before and
after each phase of cognitive interviews. As recommended
by Friedman and Hoffman-Goetz (2006), an average score
Figure 2. Illustration of the final format of the Pediatric Eating Assessment Tool.
10 American Journal of Speech-Language Pathology • 1–14
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from two readability formulas was applied to the content to
achieve a more valid and reliable estimate. At each time
point, the SMOG and Flesch-Kincaid formulas estimated
the reading level to be less than fifth grade.
Discussion
The Pedi-EAT was developed to measure the presence
or absence and frequency of a comprehensive set of discrete
behaviors related to eating. Through a systematic process
of item development (Phase I), clinical and research expert
review (Phase II), and cognitive interviews with parents
(Phases III and IV), we have gathered evidence to support the
content validity of the Pedi-EAT.
In Phase I, the use of focus groups and individual
interviews to generate an initial set of items for the Pedi-EAT
grounded the early development of the Pedi-EAT within the
perspective of parents, the intended respondents (Thoyre &
Van Riper, 2010). The focus group format was particularly
useful. As parents described problematic eating behaviors,
they clarified their descriptions for one another, often
comparing specific behaviors and differentiating between
similar-sounding feeding problems. We were alerted to terms
or phrases that families disagreed on the meaning of as well
as descriptions that they readily agree upon. Forty-one
percent of the Pedi-EAT items were developed from these
interviews. The remaining items were derived from litera-
ture and review of available instruments measuring eating
behaviors of children.
In Phase II, quantified content validity of the Pedi-
EAT was established using systematic CVI processes, defined
by Lynn (1986) and Polit and Beck (2006). The Pedi-EAT
was found to have acceptable content relevance and clarity by
the recommended number of content experts (Lynn, 1986).
The expert CVI process was informative; all but two
items with I-CVI below acceptable levels were adjusted
or eliminated according to the expert ratings and written
feedback. The two retained items (will touch food with his/her
 hands and pauses in the middle of eating to take a rest) had Limitations
both clinical support and subsequent parental support.
The process of establishing content validity of the Pedi-
The content experts strengthened the comprehen-
EAT had several limitations. The secondary data source
siveness of the Pedi-EAT by suggesting additional items.
of interviews accessed to generate items in Phase I (focus
Moreover, their comments further clarified the Pedi-EAT
group and individual interviews) represented a single group of
conceptually. Sensory items were found to reflect observed
children with Down syndrome. Field, Garland, and Williams
sensory behaviors rather than caregiver perceptions of the
(2003) found that, within a sample of children referred for
child’s experience of sensory input during feeding. Motor
feeding problems (n = 349), those with Down syndrome
items were likewise aligned to reflect what parents observe
had more oral motor delays—as evidenced by problems with
their children choosing or willing to do rather than what
chewing, moving the tongue, and lip closure—and were
children can do physically. Measuring parents’ perceptions
more selective of the type of foods eaten. The items derived
of what their children are able to do (i.e., motor skill) would
from the Phase I interviews may have oversampled in these
mix constructs and stray from the intent of the Pedi-EAT.
areas. Most of the participants rated their children as
Items that asked parents to rate the quality of their children’s
having moderate feeding difficulty. Although this response
diet were also eliminated. Although it is important to un-
indicates most would likely be able to describe a number of
derstand the impact of problematic eating behaviors, the
problematic eating behaviors, the range of behaviors may
Pedi-EAT is not designed to measure the adequacy of diet.
have been limited. However, the items from the parent in-
Separate assessments of motor skill and diet would augment
terviews were augmented by two other sources and consti-
the Pedi-EAT in future studies to increase understanding
tuted only a subset of the total number of items. A second
of factors that contribute to or are associated with prob-
limitation was the representativeness of the expert sample for
lematic eating behaviors of children.
Phase II. All invited experts had extensive research and/or
Cognitive interview methodology improved the con-
clinical experience, but the majority of those invited were
tent validity of the Pedi-EAT by using parents’ experience
speech pathologists. Because we do not know the disciplines
and expertise with their own children to shape the instru-
of the participants, there is potential for selection bias and
ment, ensuring that directions, items, and response options
overrepresentation of this area of expertise. A third limitation
were understood in the way intended. Phase III focused on
was the representativeness of the samples of parents who
assessment of parents’ interpretation of the items and eval-
participated in the cognitive interviews. Although the samples
uation of the comprehensiveness of the instrument, whereas
represented parents of children with a diverse range of eating
Phase IV focused on parents’ experience of completing the
behaviors, the majority were White, lived in two-parent
Pedi-EAT. A wide range of parents for whom the instrument
households, and had a family income greater than $50,000
is intended participated: five parents of children who were
per year. Eating behaviors of concern to low-income, non-
partially tube feeding, 19 of children with feeding difficulties,
White, single-parent families may be underrepresented; the
and 10 of children with no feeding difficulties. The Pedi-EAT
understanding of the items may be inadequately tested within
was found to be optimal for children eating at least some
these groups. Finally, the PediEAT has been validated with
solid foods. Although the instrument had a less than fifth-
families of children through the age of 10, and this sets the
grade reading level, parents asked that the language of the
upper age limit. However, because some children with de-
Pedi-EAT be simplified to improve the readability and speed
velopmental disabilities continue to make progress toward
with which they could complete the tool. For example, they
optimization of motor capabilities and lessening of difficult
asked that the phrase “his/her” be changed to “their” and for
behaviors into their second decade or longer (Buckley, Bird,
longer phrases to be shortened. Parents asked that questions
Sacks, & Archer, 2006), the instrument may be appropriate
with some similarity be grouped together to facilitate dif-
for a higher age.
ferentiating among them (e.g., gags with foods that need to be
chewed, gags with textured food like coarse oatmeal, gags with
smooth foods like pudding) and that examples be added for Future Development of the Pedi-EAT
several items. Several words were consistently suggested to The next step in the development of the Pedi-EAT is
substitute for another. For example, parents preferred the to determine its factor structure and to assess reliability
word drool to salivate and throws up to vomits. (internal consistency) on the basis of data obtained from a
Parents of children with feeding difficulties confirmed large, heterogeneous sample of parents of children with and
the relevance and comprehensiveness of the items, and without feeding difficulties. Construct validity and test–retest
parents of children without eating difficulties assisted in reliability should also be evaluated. Once the factor structure
the phrasing of items so that items were understandable has been defined (and items eliminated that do not sufficiently
to them as well. By having parents complete the Pedi-EAT load or cross-load too closely), cutoffs will need to be established
in Phase IV, we learned that the directions were not clear for children of various ages at risk for feeding problems.
enough and that a wider range of response options was
necessary. Parents suggested that the response options be
repeated at the top of each page and that in the directions Conclusion
we underline the phrase “at this time” to highlight that the We developed the Pedi-EAT within the framework
instrument is asking about current behaviors. of dynamic systems theory using a systematic process of

Thoyre et al.: Pediatric Eating Assessment Tool 11

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 instrument development and validation. The design of
the Pedi-EAT as a parent-report instrument is one of its
strengths as parents interact with their children during
mealtime across different settings and during different times
of the day, qualifying them to report on their children’s
typical eating behaviors. To our knowledge, this is the first
measure of problematic eating behaviors in children that has
taken a systematic, quantitative approach to expert content
validation as well as a systematic, qualitative approach to
evaluating content validity with parents. The Pedi-EAT has
content validity with future users and respondents of the
instrument: experiential, clinical, and research experts. The
research team plans further psychometric evaluation of
the instrument.
Acknowledgments
This research was supported by the National Institutes of
Health, National Institute of Nursing Research Center for Research
on Chronic Illness Grant P30 NR05046 (awarded to the first and
seventh authors), Institutional National Research Service Award
T32 NR007091 to support doctoral fellows in the study of Inter-
ventions for Preventing and Managing Chronic Illness (awarded to
the second and fourth authors), and Individual National Research
Service Award 5F31NR011262 (awarded to the second author).
Additional support was provided by the Royster Society of Fellows
(awarded to the third author). We would like to acknowledge and
express gratitude to the content experts and families who contrib-
uted to the development of the Pedi-EAT.
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