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Brief Assessment of Mealtime

Behavior in Children:
Psychometrics and Association
With Child Characteristics and
Parent Responses
a b
Helen M. Hendy , Laura Seiverling , Colleen T.
c d
Lukens & Keith E. Williams
a
Psychology Program , Penn State Schuylkill ,
Schuylkill Haven , PA , USA
b
Center for Pediatric Feeding Disorders, St. Mary's
Hospital for Children , Bayside , NY , USA
c
Department of Child and Adolescent Psychiatry
and Behavioral Sciences , Children's Hospital of
Philadelphia , Philadelphia , PA , USA
d
Feeding Program, Penn State Hershey Medical
Center , Hershey , PA , USA
Accepted author version posted online: 05 Dec
2012.Published online: 26 Feb 2013.

To cite this article: Helen M. Hendy , Laura Seiverling , Colleen T. Lukens & Keith E.
Williams (2013) Brief Assessment of Mealtime Behavior in Children: Psychometrics and
Association With Child Characteristics and Parent Responses, Children's Health Care,
42:1, 1-14, DOI: 10.1080/02739615.2013.753799

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DOI: 10.1080/02739615.2013.753799

Brief Assessment of Mealtime Behavior in

Children: Psychometrics and Association
Downloaded by [Pennsylvania State University] at 05:56 23 May 2014

With Child Characteristics and

Parent Responses

Helen M. Hendy
Psychology Program, Penn State Schuylkill, Schuylkill Haven, PA

Laura Seiverling
Center for Pediatric Feeding Disorders, St. Mary’s Hospital for Children,
Bayside, NY

Colleen T. Lukens
Department of Child and Adolescent Psychiatry and Behavioral Sciences,
Children’s Hospital of Philadelphia, Philadelphia, PA

Keith E. Williams
Feeding Program, Penn State Hershey Medical Center, Hershey, PA

The present study examined psychometric properties of the Brief Autism Mealtime
Behavior Inventory (BAMBI) when applied to a population of children with feeding
problems. The new scale was renamed the Brief Assessment of Mealtime Behavior
in Children (BAMBIC) for wider clinical usefulness. Parents completed question-
naires with the original BAMBI, the Child Eating Behavior Questionnaire, and
the Parent Mealtime Action Scale. The revised BAMBIC developed with factor
analysis had stronger psychometrics than the original scale and produced three sub-
scales of feeding problems: Limited Variety, Food Refusal, and Disruptive Behavior.

Correspondence should be addressed to Keith E. Williams, Feeding Program, 905 W. Governor

Rd., Hershey, PA 17033. E-mail: Feedingprogram@hmc.psu.edu

1
 2 HENDY ET AL.

More Limited Variety was reported for boys than girls, and more Food Refusal was
reported for younger children and children with special needs.

Childhood feeding problems are common, with 25% of the pediatric population
experiencing a feeding or eating problems at some time during childhood
(Manikam & Perman, 2000). Children with special needs have been found to be
at higher risk for feeding problems than children with typical development. More
specifically, children with autism spectrum disorder (ASD) were reported to have
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more feeding problems than same-aged peers with typical development (Lukens
& Linscheid, 2008; Schreck, Williams, & Smith, 2004). Among a large sample
of children (n = 350) referred to a feeding program, children with special needs
were overrepresented, with 64% of the population diagnosed with some form
of developmental disability (Field, Garland, & Williams, 2003). This finding
was replicated in another sample of 240 children referred for feeding problems
when 67% of the children were identified with special needs (Williams, Hendy,
& Knecht, 2008).
Despite the widespread occurrence of feeding problems among both children
with and without special needs, little attention has been paid to their assessment
and even less attention to the interaction between child and parent behavior. It is
known that the interplay between children and parents at mealtime can be complex
(Ventura & Birch, 2008), and research suggests that caregiver and child behavior at
mealtimes are mutually influential. For example, past research suggests that when
parents model healthy eating habits with limited consumption of snack foods and
daily consumption of fruits and vegetables, their children are more likely to learn
to eat the healthy variety of foods needed for good health and weight management
(Hendy, Williams, Camise, Eckman, & Hedemann, 2009). Also, when parents use
mealtime rules that insist children eat small amounts of the shared family meal,
their children may be more likely to reach the threshold of 8 to 10 small tastes
across time that encourage children to learn to like a food (Birch, McPhee, Shoba,
Pirok & Stineberg, 1987; Wardle, Herrera, Cooke & Gibson, 2003).
Other parent actions appear to be more in response to their children’s weight,
mealtime behavior, and other characteristics. For example, parents often respond
to children’s overweight by giving them less pressure to eat during meals and
increasing fat reduction efforts (Faith, Scanlon, Birch, Francis, & Sherry, 2004;
Grimmett, Croker, Carnell, & Wardle, 2008; Hendy et al., 2009; Spruijt-Metz,
Lindquist, Birch, Fisher, & Goran, 2002; Webber, Cooke, Hill, & Wardle, 2010).
Parents appear to respond to “picky eating” or limited food variety in chil-
dren by becoming permissive, by preparing special meals for children different
from the shared family meal, allowing children to eat whatever foods they want,
and not limiting high-fat and high-sugar snack foods that are often children’s
favorite foods (Hendy et al., 2009; Hendy, Williams, Riegel, & Paul, 2010;
Hughes, Shewchuk, Baskin, Nicklas, & Qu, 2008). Some parents admit that such
 CHILD FEEDING PROBLEMS 3

permissiveness is an effort to reduce the occurrence of the anticipated tantrums and

refusal to eat shown by children when they are given foods other than a limited set
of favorites (Rhoe, Lumeng, Appugliese, Kaciroti, & Bradley, 2006).
To examine the interaction between parent and child behavior during meal-
times, it is important to measure the range of behaviors exhibited by both parent
and child. There are several measures of parent mealtime behavior, such as the
Child Feeding Questionnaire (Birch et al., 2001) and the Parent Mealtime Action
Scale (PMAS; Hendy et al., 2009). Although neither parent behavior measure was
originally developed for use in assessment of child feeding problems, the PMAS
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was recently validated with a clinical sample of children diagnosed with feeding
problems (Williams, Hendy, Seiverling, & Can, 2011).
Several parent-completed questionnaires have also been developed to assess
feeding and feeding problems in children. One widely used scale, the Child Eating
Behavior Questionnaire (CEBQ; Wardle et al., 2001), is a 35-item measure com-
prising eight subscales. Although the CEBQ was not specifically developed for
the clinical evaluation of feeding problems, several of the subscales, such as Food
Fussiness, Slowness in Eating, and Satiety Responsiveness, may be of interest
to clinicians. Two additional measures, the Children’s Eating Behavior Inventory
(Archer, Rosenbaum, & Streiner, 1991) and the Behavioral Pediatric Feeding
Assessment Scale (Crist & Napier-Phillips, 2001), were both developed for clin-
ical use and were normed with children with feeding problems. Although both
measures cover a range of common feeding problems, neither includes questions
concerning comorbid behavior problems that often accompany feeding problems,
such as aggression or disruptive behavior (Kerwin, 1999; Linscheid, 2006).
A scale developed to address this issue was the Brief Autism Mealtime
Behavior Inventory (BAMBI; Lukens & Linscheid, 2008). The 18-item BAMBI
includes questions concerning aggressive and disruptive mealtime behaviors and
was originally developed with a sample of 108 children (68 children with ASD and
40 typically developing children) and includes the subscales of Limited Variety
(8 items), Food Refusal (5 items), and Autism Features (5 items), such as self-
injury behaviors and aggression to others. Compared with other measures such
as the CEBQ, one strength of the BAMBI is its brevity, with 18 items in the
BAMBI and 35 items in the CEBQ. The BAMBI’s measurement of aggressive
and disruptive behavior during mealtimes is significant because these behaviors
may serve as an important turning point in parent decisions to change their own
feeding practices or to take their child to a feeding clinic for professional assis-
tance. However, the psychometric evaluations used in the original BAMBI had
some limitations that reduce the reliability, validity, and clinical usefulness of the
scale. For example, in the factor analyses used, many items showed factor loadings
less than 0.40 for the subscales to which they were assigned, some items showed
equally high factor loadings for 2 different subscales, and some internal reliability
scores for subscales were lower than the traditionally expected 0.70. Additionally,
the BAMBI was not normed on children with feeding problems, a population for
 4 HENDY ET AL.

whom it may be of clinical utility. Further, the original BAMBI only compared
parent ratings of mealtime behavior in children with ASD with parents who had
typically developing children, not to parents of children with other special needs.
One purpose of the present study was to examine and strengthen the
psychometrics of the BAMBI for wider clinical usefulness as a measure of child
feeding problems relevant to the many diagnostic conditions seen in interdis-
ciplinary, often hospital-based, feeding clinics. For this more generalized use
with children of many diagnoses, the scale was renamed the BAMBIC (Brief
Assessment of Mealtime Behavior in Children). A second purpose of the present
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study was to use the improved BAMBIC measure to examine how each feeding
problem was associated with the child characteristics of age, gender, weight, and
diagnosis. A third purpose of the present study was to use the improved BAMBIC
measure to provide the first available comparison of parent responses to feeding
problems for children with three diagnostic conditions: ASD, other special needs,
and no special needs besides their feeding problems.

METHOD

Participants
Participants in the present study were 202 children admitted to a hospital feeding
program (139 boys and 63 girls; mean age = 64.2 months, SD = 42.7, range =
18–212 months). The children fell into three diagnostic groups: 57 children with
no special needs other than their feeding problems, 60 children with ASD, and
85 children with other special needs (such as genetic disorders, mental retardation,
or speech delay). All children with a diagnosis of ASD were included in the ASD
group regardless of comorbid diagnoses. The children received their diagnoses
outside of the feeding program. Every child was seen by a licensed psychologist
who verified the diagnosis through observation and clinical interview with the
child’s caregivers. Children’s height and weight were measured in the clinic for
calculation of body mass index scores (BMI = pounds/inches2 × 704.5), and for
the 190 children within the sample who were 24 months and older, the child’s BMI
percentile score (BMI%) in comparison with his or her age group using Centers
for Disease Control and Prevention charts (2000) was calculated. The mean BMI%
score was 43.8 (SD = 36.7).

Procedures and Measures

Parents completed questionnaires about demographic information on their chil-
dren and 5-point ratings for the 18 original BAMBI items of child feeding
problems (Lukens & Linsheid, 2008). Parents also were asked to give 5-point
 CHILD FEEDING PROBLEMS 5

ratings for the 35 items of the CEBQ (Wardle et al., 2001) and 3-point ratings for
the 31 items of the PMAS (Hendy et al., 2009). The CEBQ was developed with
a sample of 536 children, and the 8 dimensions of the CEBQ all have an internal
reliability above 0.72 and test-retest reliability above 0.52 (Wardle et al., 2001).
The psychometric properties of the CEBQ were verified by factor analysis in a
subsequent study (Sleddens, Kremers, & Thijs, 2008).
The PMAS was developed through both exploratory and confirmatory fac-
tor analysis involving samples of 2,008 preschoolers and school-aged children.
The PMAS has 9 subscales: Snack Limits, Positive Persuasion, Daily Fruits
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and Vegetables Availability, Use of Food Rewards, Insistence on Eating, Snack

Modeling, Special Meals, Fat Reduction, and Many Food Choices. These 9 sub-
scales had a mean internal validity of 0.62, a mean test-retest reliability of 0.62,
and a mean convergent validity of 0.69 between mothers’ and fathers’ ratings of
mothers’ use of the actions. Strong internal reliability and convergent validity was
also demonstrated for the PMAS with a group of 231 children referred to a feeding
clinic (Williams et al., 2011) (Table 1).

TABLE 1
Descriptive Statistics of Study Variables for Children With Three Diagnoses

No Special Needs Autism Other Special Needs

(n = 57) (n = 60) (n = 85)

Variable Mean (SD) Mean (SD) Mean (SD)

Child characteristics
Age, mo 50.3 (29.0) 75.6 (44.4) 65.5 (46.8)
BMI% 46.7 (34.7) 53.2 (37.2) 35.9 (36.5)
BAMBIC child feeding
problems (mean 5-point rating)
Limited Variety 4.0 (1.0) 4.3 (1.0) 3.9 (1.0)
Food Refusal 2.7 (1.0) 3.0 (1.0) 3.1 (1.0)
Disruptive Behavior 1.6 (0.9) 2.0 (1.1) 1.7 (0.9)
Parent mealtime actions
(mean 3-point rating)
Snack Limits 2.3 (0.7) 2.2 (0.8) 2.1 (0.8)
Positive Persuasion 2.5 (0.5) 2.2 (0.6) 2.4 (0.5)
FV Availability 2.4 (0.4) 2.4 (0.5) 2.4 (0.5)
Use of Rewards 1.8 (0.4) 1.7 (0.4) 1.7 (0.4)
Insistence on Eating 1.3 (0.4) 1.3 (0.4) 1.5 (0.5)
Snack Modeling 1.9 (0.4) 1.8 (0.4) 1.8 (0.4)
Special Meals 1.9 (0.4) 2.1 (0.5) 1.8 (0.4)
Fat Reduction 1.4 (0.4) 1.6 (0.5) 1.4 (0.4)
Many Food Choices 2.2 (0.4) 2.1 (0.5) 2.0 (0.5)

Note. FV, fruits and vegetables.

 6 HENDY ET AL.

RESULTS

Psychometric Properties of the BAMBI

According to Arbuckle (2007), the ideal set of scale dimensions and items within
them would be both parsimonious (or simple in the sense of including the fewest
dimensions possible) and well-fitting to the actual patterns observed in the data.
As Arbuckle describes them, “many fit measures represent an attempt to bal-
ance these two conflicting objectives—simplicity and goodness of fit” (p. 586),
with it being “impossible to define one best way to combine measures” (p. 586).
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The commonly used goodness-of-fit measures chosen for the present manuscript
included relative Chi2 , RMSEA (Root Mean Square Error of Approximation),
CFI (Comparative Fit Index), TLI (Tucker-Lewis Index), and NFI (Normed Fit
Index).
Confirmatory factor analysis for the three 18-item original BAMBI dimen-
sions (Limited Variety, Food Refusal, Autism Features) revealed mixed results for
goodness-of-fit measures: Acceptable fit was indicated by relative chi-square =
2.5 and RMSEA = 0.09, but poor fit was indicated by CFI = 0.75, TLI =
0.67, and NFI = 0.65. Internal reliability values for the original BAMBI dimen-
sions were not consistently above the recommended 0.70 value, with Cronbach’s
alphas of 0.73 for Limited Variety, 0.70 for Food Refusal, and 0.35 for Autism
Features. Convergent validity for the original BAMBI dimensions was also not as
expected: Although the BAMBI Food Refusal and Autism Features showed the
expected negative correlations with the CEBQ Food Enjoyment (p = .000, p =
.000, respectively), the BAMBI Limited Variety was not significantly associated
with the CEBQ Food Fussiness, a factor containing similar questions about food
selectivity.
Because of the mixed psychometrics found for the original 18-item BAMBI,
we developed a new version of the scale, which we called the Brief Assessment of
Mealtime Behaviors in Children, or BAMBIC, using factor analysis with varimax
rotation on the 18 items from the original BAMBI but with requirements that
all dimensions include at least 3 items and that all items show factor loadings
of 0.50+ in only one dimension. Eight original BAMBI items were eliminated
because they failed to meet these criteria: item 4 (for not loading 0.50+ on any
dimension), item 18 (for loading 0.50+ on more than one dimension), and items
3, 9, 12, 14, 16, and 17 (for loading on dimensions with only 2 items). Repeating
the factor analysis without these 10 items revealed 3 subscales similar to those
found in the original publication: Limited Variety, Food Refusal, and a dimension
we renamed Disruptive Behavior (Table 2).
The new BAMBIC version of the scale showed acceptable to strong goodness-
of-fit values with relative chi-square = 2.6, RMSEA = 0.09, CFI = 0.91, TLI =
0.85, and NFI = 0.87. Internal reliability values for all BAMBIC dimensions were
 CHILD FEEDING PROBLEMS 7

TABLE 2
Factor Analysis Results That Developed the Revised BAMBIC Dimensionsa

Factor
Scale No. and Item Loading

Limited Variety (Cronbach’s alpha = 0.79)

15. My child accepts or prefers a variety of foods. −0.878
10. My child is willing to try new foods. −0.807
11. My child dislikes certain foods and won’t eat them. 0.742
13. My child prefers the same foods at each meal. 0.690
Food Refusal (Cronbach’s alpha = 0.70)
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2. My child turns his/her face or body away from food. 0.883

8. My child closes his/her mouth tightly when food is presented. 0.796
1. My child cries or screams during mealtimes. 0.525
Disruptive Behavior (Cronbach’s alpha = 0.73)
5. My child is aggressive during mealtimes (e.g., hitting, kicking, scratching others). 0.842
6. My child displays self-injurious behavior during mealtimes (e.g., hitting self, 0.819
biting self).
7. My child is disruptive during mealtimes (e.g., pushing/throwing utensils, food). 0.690

Note. The following items were eliminated: 3. My child remains seated at the table until the meal
is finished; 4. My child expels (spits out) food that he/she has eaten; 9. My child is flexible about
mealtime routines (e.g., times for meals, seating arrangements, place settings); 12. My child refuses
to eat foods that require a lot of chewing (e.g., eats only soft or pureed foods); 14. My child prefers
“crunchy” foods (e.g., snacks, crackers); 16. My child prefers to have food served in a particular way;
17. My child prefers only sweet foods (e.g, candy, sugary cereals); 18. My child prefers food prepared
in a particular way (e.g., mostly fried foods, cold cereals, raw vegetables).
a Goodness-of-fit values of relative chi-square = 2.63, RMSEA = 0.089, CFI = 0.91, TLI = 0.85,

and NFI = 0.87.

above the recommended 0.70, with Cronbach’s alphas of 0.79 for Limited Variety,
0.70 for Food Refusal, and 0.79 for Disruptive Behavior. Convergent validity for
all dimensions of the BAMBIC was shown by the expected correlations with
CEBQ dimensions, with Limited Variety positively correlated with the CEBQ
Food Fussiness (p = .000) and Food Refusal and Disruptive Behavior negatively
correlated with the CEBQ Food Enjoyment (p = .000 and p = .007, respec-
tively). Because the revised 10-item BAMBIC demonstrated more consistent
psychometrics (in goodness-of-fit, internal reliability, and convergent validity)
than the original 18-item BAMBI, we chose the new BAMBIC for the following
analyses that examined how child feeding problems were associated with child
characteristics and parent responses.

Child Characteristics Associated With BAMBIC Feeding Problems

The analysis of covariance (ANCOVA) that examined how the BAMBIC problem
of Limited Variety was associated with child age, BMI%, gender, and diagnosis
 8 HENDY ET AL.

revealed only a significant main effect for gender (F = 4.65, df = 1/182, p =

.032, partial eta-square effect size = 0.025), with boys showing more Limited
Variety than girls (boy’s mean = 4.2, SD = 1.0; girl’s mean = 3.8, SD = 1.1).
The ANCOVA for the BAMBIC problem of Food Refusal revealed a signifi-
cant effect for the covariate of age (F = 16.69, df = 1/182, p = .000, partial
eta-square effect size = 0.084), with more Food Refusal in younger children.
A significant main effect was also found for diagnosis (F = 5.23, df = 1/182,
p = .006, partial eta-square effect size = 0.054), with the most Food Refusal
shown by children with special needs other than ASD, followed by children with
ASD, followed by children with no special needs (mean = 3.1, SD = 1.0; mean
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= 3.0, SD = 1.0; mean = 2.7, SD = 1.0; respectively). The ANCOVA for the
BAMBIC problem of Disruptive Behavior revealed no significant main effects
or interaction effects for age, BMI%, gender, or diagnosis, a finding that sup-
ports the change of this dimensions name from its original name of “Autism
Features.”

Parent Responses to BAMBIC Feeding Problems

For feeding-clinic children without special needs, the multiple regression analysis
revealed that when these children showed high levels of the BAMBIC prob-
lem of Limited Variety, parents tended to show less Insistence on Eating and
more Positive Persuasion (p = .021 and p = .024, respectively). However, when
these children showed high levels of the BAMBIC problems of Food Refusal and
Disruptive Behavior, parents did not appear to change any of the nine mealtime
actions (Table 3).
For feeding-clinic children with ASD, the multiple regression analysis revealed
that when these children showed high levels of the BAMBIC problem of Limited
Variety, parents tended to show more preparation of Special Meals for them dif-
ferent from the shared family meal (p = .047). However, when these children
showed high levels of the BAMBIC problems of Food Refusal and Disruptive
Behavior, parents did not appear to change any of the nine mealtime actions
(Table 3).
For feeding-clinic children with other special needs besides ASD, the multi-
ple regression analysis revealed that when these children showed high levels of
the BAMBIC problem of Limited Variety, parents tended to offer them Many
Food Choices of whatever they want to eat and to prepare Special Meals for
them different from the shared family meal (p = .037 and p = .019, respec-
tively). When these children showed high levels of the BAMBIC problem of
Food Refusal, parents tended to set fewer Snack Limits (p = .033). When these
children showed high levels of the BAMBIC problem of Disruptive Behavior
during meals, parents responded with more Positive Persuasion (p = .022)
(Table 3).
 Downloaded by [Pennsylvania State University] at 05:56 23 May 2014

TABLE 3
Multiple Regression Results for Parent Responses to Three BAMBIC Feeding Problems by Children With Three Diagnoses: No Special
Needs, Autism, Other Special Needs (Age and Gender Were Partialled Out First)

No Special Needs Autism Other Special Needs

Beta t p Beta t p Beta t p

Limited Variety
Snack Limits
Positive Persuasion 0.335 2.35 0.024
FV Availability
Use of Rewards
Insistence on Eating −0.311 2.40 0.021
Snack Modeling
Special Meals 0.326 2.06 0.047 0.292 2.42 0.019
Fat Reduction
Many Food Choices 0.264 2.14 0.037
(R2 = 0.37, F(4, 38) = 5.49, p = .001) (R2 = 0.24, F(3,34) = 3.57, p = .024) (R2 = 0.18, F(4,57) = 3.21, p = .019)
Food Refusal
Snack Limits −0.264 2.18 0.033
Positive Persuasion
FV Availability
Use of Rewards
Insistence on Eating
Snack Modeling
Special Meals
Fat Reduction
Many Food Choices
(not significant, p = .211) (not significant, p = .066) (R2 = 0.21, F(3,58) = 5.07, p = .003)
(Continued)

9
 Downloaded by [Pennsylvania State University] at 05:56 23 May 2014

10
TABLE 3
(Continued)

No Special Needs Autism Other Special Needs

Beta t p Beta t p Beta t p

Disruptive Behavior
Snack Limits
Positive Persuasion 0.283 2.35 0.022
FV Availability
Use of Rewards
Insistence on Eating
Snack Modeling
Special Meals
Fat Reduction
Many Food Choices
(not significant, p = .173) (not significant, p = .727) (R2 = 0.16, F(3,58) = 3.70, p = .017)

Note. FV, fruits and vegetables.

 CHILD FEEDING PROBLEMS 11

DISCUSSION

One purpose of the present study was to examine the psychometrics of the orig-
inal 18-item BAMBI and revise it to make it a more widely useful measure of
child feeding problems relevant to the many diagnostic conditions seen in hospital-
based feeding clinics. Comparisons of the original 18-item BAMBI with a revised
10-item BAMBIC found stronger and more consistent psychometrics for the
BAMBIC in goodness-of-fit for the scale dimensions, internal reliability, and con-
vergent validity with expected dimensions of the widely used CEBQ (Wardle et al.,
Downloaded by [Pennsylvania State University] at 05:56 23 May 2014

2001). The BAMBIC was found to measure 3 types of child feeding problems:
Limited Variety, Food Refusal, and Disruptive Behavior. The BAMBIC was devel-
oped to be used with a range of children with feeding problems. As the BAMBI
has not yet been used in studies subsequent to the original study in which it was
developed, it is not clear whether the new, abbreviated measure, the BAMBIC, has
any less clinical utility. Further research with additional populations of children
will need to be conducted to examine this issue.
The second purpose of the present study was to see how BAMBIC child feed-
ing problems were associated with the child characteristics of age, weight, gender,
and diagnosis so clinicians could identify children at greatest risk for each prob-
lem. Only child gender, age, and diagnosis were significantly related to BAMBIC
problems, with more Limited Variety reported for boys than girls and more
Food Refusal for younger children and children with special needs. Surprisingly,
children’s BMI% scores were not associated with any of the BAMBIC feed-
ing problems. However, because 50% or more of the feeding-clinic children
in the present sample were consuming commercially prepared nutrition supple-
ment drinks, their usual BMI% scores may have been distorted (Hendy et al.,
2010).
The third purpose of the present study was to use the improved BAMBIC
measure to provide the first available comparison of parent responses to feeding
problems for children referred to a hospital feeding clinic with three diagnos-
tic conditions: no special needs, ASD, and other special needs. Parent mealtime
responses to BAMBIC feeding problems were found to differ according to the
child’ diagnosis, with parents more likely to respond with permissive actions (such
as more Special Meals, Many Food Choices, few Snack Limits) for children with
special needs than for children with no special needs. This pattern was especially
true for children with special needs other than ASD, with parents responding to
2 of 3 BAMBIC types of feeding problems (Limited Variety, Food Refusal) with
some form of permissive action. Also, when these special needs children showed
Disruptive Behavior during meals (such as self-injury or aggression to others), par-
ents responded with increased use of Positive Persuasion (e.g., saying how good
the food tastes, how much friends and siblings and parents like the food), whereas
parents of children with ASD or no special needs did not make adjustments to
 12 HENDY ET AL.

their mealtime actions when their children showed Disruptive Behavior. One inter-
pretation for these patterns is that when parents of other special needs children
see their health and survival as at risk, they become more willing to try “any
means necessary” to get calories into their child immediately, with healthy diet
variety and weight management a distant and secondary concern. Past research
found that when parents become excessively permissive, such as serving children
their favorite special meals different from the family meal, their children may
consume enough calories to maintain normal weight status, but at the cost of per-
petuating their limited diet variety (Hendy et al., 2010). Alternatively, they may
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perceive their child’ feeding problems as attributable to the disorder and “beyond
their control” with the hope of simply avoiding mealtime tantrums from their
children.

Study Limitations
There are several limitations to this research. Although we categorized our pop-
ulation into 3 groups, children with ASD, children with other special needs, and
children without special needs, this categorization was based on review of records
and clinical interview rather than direct assessment, so the validity of the chil-
dren’s diagnoses were unclear. Further, had the sample size been larger, we could
have examined additional clinical groups rather than having the broad grouping
of “other special needs.” The generalization of these results may be problematic
in 2 ways. First, the sample of children used in this study was referred for feed-
ing problems, so it is unclear how these results extend to children without feeding
problems. Second, the children in this sample were all referred to the same feed-
ing program, so it is unclear how this sample reflects the greater population of
children with feeding problems because children with feeding problems who are
not referred to hospital-based programs may have fewer medical issues or feeding
problems that are less severe than children in this sample.

Future Research
Future research could investigate parent attributions for their children’s feeding
problems, how these attributions differ across diagnoses, and how these attribu-
tions are associated with parent mealtime actions. As well, examination of parent
perceptions of threats associated with child feeding problems, such as a child’
fatigue, infection, slowed growth, peer teasing, later eating disorders, or other seri-
ous health problems, is of interest. Finally, parent perception of barriers to taking
action to try to change their children’s feeding problems is an important considera-
tion. According to the Health Belief Model (Janz & Becker, 1984), such perceived
threats for the child’ feeding problem and perceived barriers for caregivers to take
action are the most powerful predictors of parents making changes to their child
 CHILD FEEDING PROBLEMS 13

feeding practices. Greater understanding of such parent perceptions and how they
are associated with “turning points” in parent decisions to take action could guide
clinicians to present their services to parents in ways that enhance parent confi-
dence and participation. Future research also needs to include samples of children
without special needs or feeding problems in the development of normative data.
To further validate this questionnaire, future research could compare direct obser-
vation of mealtimes with questionnaire data to examine the correspondence of the
two sources of information.
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Implications for Practice

The BAMBIC provides clinicians who work with children with feeding problems
a brief, easy-to-use tool for gathering information that is not collected through the
use of other current instruments. Unlike most other instruments, the BAMBIC
measures inappropriate behaviors reported in children with feeding problems
(Williams et al., 2008). The BAMBIC expands the clinical utility of the BAMBI,
which was developed to assess feeding problems in ASD, to a measure that is
appropriate for assessing all children. Although the BAMBIC was not designed
to measure all aspects of feeding and feeding problems, it can serve as one
component of an assessment of feeding problems.

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