J Child Fam Stud (2017) 26:3167–3178
DOI 10.1007/s10826-017-0800-y
ORIGINAL PAPER
Early Feeding, Child Behaviour and Parenting as Correlates of
Problem Eating
Michelle Adamson1 Alina Morawska2
●
Published online: 15 June 2017
© Springer Science+Business Media New York 2017
Abstract Mealtimes are a common source of stress for
families. Examining factors related to problem eating may
provide markers by which to identify families requiring
assistance and salient targets for treatment. The current
study investigated parenting practices and cognitions, gen-
eralisation of child behavioural issues, and early feeding
history as they relate to problem eating in typically devel-
oping young children. We compared a community sample
of 105 parents of 1.5–6-year-old children via survey and
observation with 96 parents seeking treatment for their
child’s problem eating. History of problems with breast-
feeding, χ2(1) = 3.88, p = .049, and the transition to solids,
χ2(1) = 7.27, p = .007, were more common among problem
eaters than comparisons. Problem eaters had a greater
number of problem behaviours outside of mealtimes,
F(1181) = 10.88, p = .001, though not more frequently than
comparisons and not to clinical levels, F(1181) = 1.81,
p = .181. Parents of problem eaters reported more unhelpful
mealtime parenting strategies, F(1155) = 22.59, p < .001,
yet general parenting style was similar by group, F(1187) =
0.42, p = .527. Parents’ cognitions about mealtimes,
F(1155) = 119.81, p < .001, including mealtime-specific
self-efficacy, F(1155) = 171.30, p < .001, were poorer
amongst problem eaters, and were the only factors to predict
problem eating in the total sample. General parenting self-
efficacy was poorer in parents of problem eaters
* Michelle Adamson
michelle.adamson@usq.edu.au
1
School of Psychology and Counselling, University of Southern
Queensland, Toowoomba, QLD, Australia
2
Parenting and Family Support Centre, School of Psychology, The
University of Queensland, Brisbane, QLD, Australia
(Behaviour: F(1187) = 42.36, p < .001; Setting: F(1187) =
10.64, p = .001). Evidence of feeding issues in infancy may
support early detection of and intervention for later problem
eating. The significance of broader child behaviour is less
clear. Parent factors, particularly those specific to meal-
times, and cognitive in nature (including mealtime parent-
ing self-efficacy) clearly differentiated the groups, and
represent important targets for intervention.
Keywords Feeding Child Parent Mealtimes
● ● ● ●
Behaviour
Introduction
Problem eating is common during early childhood (de Moor
et al. 2007b). Refusing to eat a reasonable range or amount
of food, or to perform behaviour necessary for eating (such
as self-feeding and manipulating food and utensils appro-
priately) can cause significant stress for parents (Greer et al.
2008), and may result in physical and health detriments
(e.g., de Moor et al. 2007b) and long-standing eating issues
(Marchi and Cohen 1990). Identification of effective treat-
ments is therefore important, and should be guided by
factors thought to cause and maintain feeding issues. Var-
ious medical, developmental and oral/motor factors have
been implicated in the development and maintenance of
feeding problems (e.g., Johnson and Harris 2004; Williams
et al. 2008). However, feeding problems often persist
beyond remission of (de Moor et al. 2005) or independent
of these biological or developmental factors (e.g., de Moor
et al. 2007b; Lewinsohn et al. 2005).
3168
Various antecedents and consequences in the mealtime
environment, in particular those administered by parents,
have been associated with feeding problems (Blissett et al.
2011; de Moor et al. 2005). Aversive parenting strategies
such as berating, threatening and force feeding have been
associated with fussy eating (Crist and Napier-Phillips
2001; de Moor et al. 2007b) and food refusal (Orrell-
Valente et al. 2007), and the use of physical punishment,
criticism and negative social attention with child non-
compliance (Sanders, Patel, et al. 1993). More permissive
strategies like coaxing, providing alternate meals and
allowing food between meals have been associated with
selective eating (Crist and Napier-Phillips 2001; Williams
et al. 2008). Little or poorly timed praise, more frequent yet
less specific instruction (Sanders et al. 1997) and offering
alternate food have been shown to differentiate parents of
picky eaters (Carruth et al. 1998) and those with broader
feeding issues from comparisons (Crist and Napier-Phillips
2001; Sanders, Patel, et al. 1993). These are thought to
result from negative cycles of interaction common between
problem eaters and their parents, whereby problem eating
invites increasingly coercive responses from parents to
force the child to eat, resulting in even more avoidant and
disruptive behaviour by the child (Sanders, Patel, et al.
1993). Parenting practices are a significant predictor of child
feeding problems (Johnson and Harris 2004; Sanders, Patel,
et al. 1993), and suggested as more powerful than satiety
mechanisms in regulating children’s intake (Mrdjenovic and
Levitsky 2005). Behavioural interventions based on mod-
ifying such mechanisms have been shown to reduce pro-
blem eating (Adamson et al. 2013; Morawska et al. 2014).
While there is clear evidence for the effects of parenting
on child mealtime problems, the existing literature on
parent–child interactions at mealtimes has tended to focus
on children with chronic illness or disability (Crist and
Napier-Phillips 2001), feeding disorder, or obesity (Wil-
liams et al. 2008). While these are of great clinical impor-
tance, limited conclusions may be drawn for children who
are otherwise healthy and typically developing, and who
represent a larger number of children (Lewinsohn et al.
2005). Likewise, while general parenting style has been
modestly correlated with child mealtime behaviour (de
Moor et al. 2007a), examination of this construct amongst
parents of problem eaters is relatively limited. Questions
also remain regarding whether problem eaters display
broader behavioural issues, with studies suggesting general
child behaviour issues among problem eaters (McDermott
et al. 2008; Sanders et al. 1997) and improved general
behaviour following an 8-week mealtime intervention
(Adamson et al. 2013) but not a single session intervention
(Morawska et al. 2014).
Of emerging interest are parental cognitions (Morawska
and Sanders 2007). Parental beliefs, expectations and
J Child Fam Stud (2017) 26:3167–3178
attributions about feeding may act as a distal mechanism in
the maintenance of feeding difficulties by determining
parental responses to child mealtime behaviour (Berlin et al.
2009; Chavira et al. 2000). Research has linked childhood
feeding issues with parents’ causal inferences for feeding
(e.g., due to temperament, or being a good or bad parent;
Bramhagen et al. 2006) and concern about childhood obe-
sity (Pugliese et al. 1987) though, like the parent cognition
literature more generally, research into parent cognitions in
the specific areas of feeding is limited (Farrow and Blissett
2006). Likewise, despite a wealth of anecdotal evidence
suggesting parents lack confidence at the task of feeding
(e.g., de Moor et al. 2007a), we found only two studies that
have investigated parental self-efficacy amongst parents of
problem eaters (Dunne et al. 2007; Sanders et al. 1997).
This research did not find differences in parental self-
efficacy between parents of problem eaters and compar-
isons, though each measured parents’ perceptions of their
competence in the parenting role broadly; it remains to be
seen whether self-efficacy is lower in relation to the task of
feeding specifically.
Further study is thus needed of the correlates of problem
eating, particularly among young children who are devel-
oping normally (de Moor et al. 2007b; Nicholls et al. 2001),
to better inform assessment and intervention. The present
study investigated particular child and parent factors as they
relate to problem eating in a sample of 201 parents of
typically developing young children, 96 of whom were
concerned about and seeking assistance for their child’s
eating. Of primary interest were mealtime-specific parenting
practices, cognitions and self-efficacy: specifically, parents
of problem eaters were predicted to report greater use of
maladaptive mealtime parenting strategies, and greater
endorsement of unhelpful parental cognitions about meal-
times than comparisons, in addition to lower self-efficacy
about parenting at mealtimes. Of secondary interest were
non-mealtime variables: we expected that self-efficacy
related to the task of parenting generally would be similar
by group given earlier findings, though predictions related
to general child behaviour (including external to mealtimes)
and how parents respond to child behaviour (parenting
style) by group were exploratory.
Method
Participants
Participants were self-nominated parents of young Aus-
tralian children with and without feeding concerns drawn
from a broader research program, including an intervention
trial for children with problem eating (Adamson et al.
2013). Both controls and problem eaters were sought via the
J Child Fam Stud (2017) 26:3167–3178 3169

same recruitment materials advertising the research to par- Table 1 Demographic Characteristics of the Sample
ents at general practice clinics, childcare centres, kinder- Variable Comparisons Problem χ2 (df) p
gartens, schools and community health centres in regional N (%) eaters
and metropolitan Queensland and on a number of Aus- N (%)
tralian parenting websites. Parents of children aged Marital status 105 96 5.04 (4) .283
approximately 1.5–6 years, without complex medical or Single 1 (0.95) 3 (3.13)
developmental conditions, and not already receiving pro- Married 84 (80.00) 82 (85.42)
fessional assistance for behaviour and/or feeding were eli- Defacto 15 (14.29) 7 (7.29)
gible to participate. A total of 201 families participated Separated 5 (4.76) 3 (3.13)
including 96 parents who responded affirmatively to the
Divorced 0 1 (1.04)
question, Are you concerned about your child’s eating? and
Household 105 94 3.60(3) .308
were seeking assistance for this (problem eaters) and 105
Original 100 (95.24) 87 (92.55)
families who indicated no concern about their child’s
Step 0 1 (1.06)
feeding and/or were not seeking assistance (non-problem
Sole parent 5 (4.76) 6 (6.38)
eaters) and thus acted as comparisons. Data used in the
Education 102 93 4.41(4) .353
current study was cross-sectional, collected at baseline of
the intervention study, in order to compare parents of pro- Year 10/11 5 (4.90) 7 (7.53)
blem eaters with a control sample. Parents of problem eaters Year 12 8 (7.84) 9 (9.68)
progressed on to the intervention study so additionally were TAFE/College 18 (17.65) 15 (16.13)
living in the geographical areas where the intervention was Trade/Apprenticeship 0 3 (3.23)
offered (regional and metropolitan Queensland). Tertiary 71 (69.61) 59 (63.44)
Table 1 displays demographic data. Respondents were Work hours per week 102 94 7.16 (5) .209
mostly mothers (98.51%) within original two-parent None 33 (32.35) 33 (35.11)
families with 1–5 children, who had been able to meet <10 h 12 (11.76) 9 (9.57)
household expenses in the last 12 months. Male and female 10–20 h 17 (16.67) 10 (10.64)
children were approximately equally represented, with a 20–30 h 23 (22.55) 22 (23.40)
mean age of 2.81 years (SD = 1.01). Problem eaters were 30–40 h 15 (14.71) 14 (14.89)
older (M = 3.14 years, SD = 1.10) than comparisons (M = >40 h 2 (1.96) 6 (6.38)
2.52 years, SD = 0.81), t(173.33) = −4.52, p < .001. Pro- Able to meet expenses 103 94 0.00 (1) .975
blem eating ranged in duration from several months to Yes 93 (90.29) 85 (90.43)
years, and included refusing to self-feed, leaving the table, No 10 (9.71) 9 (9.57)
food refusal and selective eating. Most parents in this group
t = Independent samples t-test; χ = Pearson’s chi-square. Numbers in
2
were a bit (45.8%) or quite (36.5%) concerned about their each analysis vary due to missing data. TAFE technical and further
child’s eating on the above question. education

Procedure

Participants were screened via telephone, at which time
eligible and consenting parents were directed to online
measures and an observation was scheduled for the next
available opportunity. On completion of the measures,
parents in the comparison group were thanked for their
participation by receiving general feedback and a movie/
food voucher. Families in the problem eaters group pro-
gressed on to the intervention study to receive a free
mealtime intervention. The research was conducted with
ethical approval from The University of Queensland.
Measures
Parents completed a suite of measures electronically. This
included a demographic questionnaire adapted from the
Family Background Questionnaire (Sanders et al. 2001)
covering child age, gender, family composition, parental
education and employment, early feeding history (Did you
experience any of the following in their 1st year: Difficulty
breastfeeding? Difficulty moving from breast/bottle to solid
foods?), parental concern about the child’s eating, and
whether the parent wanted assistance with mealtimes.
Child feeding behaviour, mealtime parenting strategies
and parental cognitions were assessed via the 90-item Par-
ent and Toddler Feeding Assessment (PATFA; Adamson
and Morawska 2016). Parents first rated 21 common child
feeding problems (e.g., spitting food out) in three ways: a)
frequency, on a five-point scale from 1 (never) to 5 (almost
always); b) whether each was problematic (yes/no); and c)
their confidence in managing each on a 10-point scale
(higher scores indicating greater self-efficacy). Parents then
rated how frequently they used 30 strategies at mealtimes
3170
on the five-point scale above. This included strategies
deemed helpful (e.g., eating with the child) and unhelpful
(e.g., force-feeding), with the former reverse-scored to give
a measure of the frequency of maladaptive mealtime par-
enting strategies. Finally, parents rated their level of
agreement with 39 statements related to cognitive and
emotional aspects of feeding (e.g., I feel defeated by my
child), including four statements relevant to partners (e.g.,
my child’s behaviour at mealtimes upsets my partner), on a
five-point scale, higher scores indicating stronger agree-
ment. This included statements deemed helpful (e.g., per-
ception of supports) and unhelpful (e.g., attributing feeding
issues to deliberate actions of the child), with the former
reverse-scored to give a measure of agreement with
unhelpful parental cognitions about mealtimes. Responses
were summed to provide six summary scores: the frequency
of child feeding problems, the number of child feeding
problems, parent mealtime self-efficacy, the frequency of
maladaptive mealtime parenting strategies, agreement with
unhelpful parental cognitions about mealtimes, and agree-
ment with unhelpful cognitions related to partners. The
PATFA has good test–retest reliability (r = .68–.89) and is
well correlated with the total score of the Children’s Eating
Behavior Inventory (CEBI; Archer et al. 1991) (r = .50
−.72; Adamson and Morawska 2016). It has been shown to
differentiate problem eaters and non-problem eaters
(Adamson and Morawska 2016) and capture post-
intervention change (Adamson et al. 2013; Morawska
et al. 2014). The six summary scores had adequate to
excellent internal consistency (α = .65–.97) in the current
sample.
The Eyberg Child Behaviour Inventory (ECBI; Eyberg
and Pincus 1999) assessed disruptive child behaviour.
Parents rated 36 behavioural issues (e.g., whines) on a
seven-point scale as to how often their child demonstrates
this behaviour (Intensity), and whether it is a problem for
the parent (Problem) using a yes/no format. The ECBI is a
sensitive measure of change with regard to child behaviour
problems, with good internal consistency in the current
study (α = .93 and .91 for the Problem and Intensity scales
respectively), and test–retest reliability (r = .86; Eyberg and
Robinson 1982). Clinical cut-off scores of ≥131 and ≥15
have been suggested for the intensity and problem scales,
respectively (Eyberg and Pincus 1999).
The Parenting Scale (PS; Arnold et al. 1993) measured
general parenting style. Parents rated their usual response to
child behaviour on 30 scenarios using a seven-point scale
between two anchors (one representing an effective
response and the other ineffective). Responses were then
summed (higher scores indicating less effective parenting
style). The total score had good internal consistency in the
current study (α = .87) and has good test–retest reliability
(r = .84; Locke and Prinz 2002). A clinical cut-off score of
J Child Fam Stud (2017) 26:3167–3178
≥3.2 was employed for the total score based on Arnold et al.
(1993).
Parental self-efficacy was assessed by the Parenting
Tasks Checklist (PTC; Sanders and Woolley 2005). Parents
rated their confidence in managing 28 challenging child
behaviours (e.g., tantrums) and settings (e.g., shopping) on
a ten-point scale (10 being most confident). Scores were
averaged into two subscales: Behavioural self-efficacy and
setting self-efficacy, both with excellent internal con-
sistency in the current study (α = .97 and .92 respectively).
The PTC has been shown to distinguish mothers seeking
assistance for their child’s behaviour from controls (Sanders
and Woolley 2005). Community and clinic group means
from Sanders and Woolley 2005 were used to assess
Behaviour and Setting scale scores.
Observations
An evening meal was filmed to capture parent and child
mealtime behaviour. Strategies to ensure authenticity of the
observations included filming in the home at the time
nominated by the parent without research assistants present,
asking parents to provide a normal meal to their child and to
act as they usually would, and checking afterward with
parents that the mealtime was typical of the child/family
(Janicke Mitchell and Stark 2005). When mealtimes were
not reported as typical, a second observation session was
attempted, and the more typical of the two sessions was
coded. Most problem eaters were filmed as this was part of
the intervention study (n = 74, 77.08%; a minority either
declined observation or did not continue on to the inter-
vention study and were not coded). One-third of non-
problem eaters (n = 33, 31.34%) were filmed as non-
problem eaters could reside anywhere in the state, this
number reflected those consenting to filming who lived
locally. These families did not differ on demographic and
clinical variables from comparison families not observed.
Video footage was analysed by a coder blind to study
hypotheses and the group membership of each family using
the Mealtime Observation Schedule (MOS; Sanders, Le
Grice, et al. 1993). The MOS employs a partial interval time
sampling procedure to record the presence of 16 child
behaviours and 14 parent behaviours in consecutive 10-s
intervals (see Table 2). This yielded four summary measures
regarding the percentage of intervals in which the child
demonstrated appropriate (e.g., eating; Child positive) or
inappropriate behaviour (e.g., noncompliance; Child nega-
tive) and the parent displayed positive (e.g., praise; Parent
positive) or aversive behaviour toward the child (e.g.,
negative contact; Parent negative). The MOS is an estab-
lished method of coding that has been shown to have good
interrater reliability (mean k parent codes = .83; child
codes = .80) and reliably differentiate children with and
J Child Fam Stud (2017) 26:3167–3178 3171

Table 2 Observational codes for Mealtime Observation Schedule (general child behaviour) and parenting factors (mealtime
(Sanders, Le Grice, et al. 1993)
parenting practices, cognitions, and self-efficacy; general
Child codes Parent codes parenting style and self-efficacy) in predicting child feeding
difficulties.
Positive codes Praise
Appropriate verbal interaction Positive contact
Engaged activity Aversive contact
Results
Affection Positive specific instruction
Appropriate eating Aversive specific instruction
Missing data was minimal (not exceeding 15.42% for any
Request for food Positive vague instruction
item, with most items missing no or few values) and there
Negative codes Aversive vague instruction were no outliers. Violations of the homogeneity of
Non-compliance Positive social attention variance–covariance matrices assumption were addressed
Complaint Aversive social attention by equalising sample size via random deletion of cases
Aversive demand Affection (Tabachnick and Fidell 1996). Between 5 and 11 cases were
Physical negative Presentation of food deleted per MANCOVA, and did not change the outcomes
Oppositional Removal of Food of analyses.
Interrupt Non-interaction We first checked if children in the problem eaters group
Food refusal Blank parent showed more problems at mealtimes. Parents of problem
Vomit eaters rated a greater number and frequency of mealtime
Playing with food issues on the PATFA than comparisons, F(2173) = 199.36,
Leaving the table p < .001 (see Table 3). Likewise, child observational data
Blank child indicated significantly lower rates of positive behaviour at
mealtimes and more instances of negative behaviour among
problem eaters, F(2103) = 9.40, p < .001 (see Table 4).
without feeding difficulties (Sanders, Patel, et al. 1993).
Coders were trained over several sessions and met peri- Early Feeding History
odically throughout coding to minimise drift. Approxi-
mately 20% of tapes were randomly allocated to a second Two chi-square tests compared problem eaters to non-
coder and interrater reliability values were calculated based problem eaters on early feeding history. A history of
on correlations between raters in terms of the presence or breastfeeding problems was reported significantly more
absence of each code in each interval. Kappa was not often in problem eaters (38.30%, n = 36) than comparisons
appropriate as base rates of behaviour codes were low. (25.24%, n = 26), χ2(1) = 3.88, p = .049. Problem eaters
Interrater correlations for the summary codes were moderate were also more likely to have had problems when solids
to high (r = .45−.79). were introduced, χ2(1) = 7.27, p = .007, with 20% of pro-
blem eaters (n = 19) reported to have had early difficulties
Data Analyses compared to 6.9% (n = 7) of non-problem eaters.

Preliminary analyses compared the problem and non-
problem eater groups on demographic variables to ensure
sample equivalency. The presence of early feeding pro-
blems was examined by group using chi-square procedures.
A series of multivariate analyses of covariance (MAN-
COVA) compared problem eaters to comparisons on the
outcome measures in conceptually-similar groups:
mealtime-specific parenting variables (parenting practices,
cognitions and self-efficacy, as measured by the PATFA),
general parenting variables (parenting style and self-effi-
cacy, as measured by the PTC and PS), and general child
behaviour (as measured by the ECBI). Child age was
included as a covariate given it differed by group. Follow-
up of significant effects was done via univariate analyses of
covariance (ANCOVA). Hierarchical regression analyses
then examined the relative importance of these child
Mealtime-Specific Parenting Variables
The four parent summary scores on the PATFA were ana-
lysed via a between-groups MANCOVA with child age as
covariate. A significant main effect was found, F(4152) =
53.16, p < .001, and univariate analyses indicated sig-
nificant differences on all four scores (see Table 3). Namely,
parents of problem eaters reported more frequent use of
unhelpful mealtime strategies, F(1155) = 22.59, p < .001,
greater agreement with more unhelpful cognitions at meal-
times, F(1155) = 119.81, p < .001, including those related
to partners specifically, F(1155) = 12.28, p = .001, and
significantly lower mealtime self-efficacy than parents of
non-problem eaters, F(1155) = 171.30, p < .001.
Individual PATFA parent strategy and cognition items
were compared by group via a series of individual t-tests,
3172 J Child Fam Stud (2017) 26:3167–3178

Table 3 Problem eaters and

Measure Comparisons Problem eaters F (df) p Cohen’s d
comparisons on parent-report
measures N M (SD) N M (SD)

PATFA
Frequency of child feeding 88 39.80 (7.36) 88 62.87 (9.79) 268.64 (1173) <.001 2.74
problem
Number of child feeding 88 1.86 (2.37) 88 11.21 (4.36) 269.91 (1173) <.001 2.78
problems
Parent mealtime self- 79 172.08 (25.99) 79 104.19 (34.73) 171.30 (1155) <.001 2.22
efficacy
Unhelpful parent mealtime 79 62.56 (9.10) 79 69.17 (12.22) 22.59 (1155) <.001 0.64
strategies
Unhelpful parent mealtime 79 79.51 (11.35) 79 99.44 (10.91) 119.81 (1155) <.001 1.80
cognitions
Unhelpful cognitions 79 8.66 (2.70) 79 10.48 (2.81) 12.28 (1155) .001 0.67
related to partners
ECBI
Intensity scale 92 103.11 (22.97) 92 114.13 (27.79) 1.81 (1181) .181 0.47
Problem scale 92 4.64 (5.37) 92 9.27 (7.46) 10.88 (1181) .001 0.77
PS
Total score 95 2.66 (0.57) 95 2.82 (0.74) 0.42 (1187) .527 0.25
PTC
Behaviour 95 8.69 (1.16) 95 6.95 (1.94) 42.36 (1187) <.001 1.09
Setting 95 8.94 (0.85) 95 8.45 (1.38) 10.64 (1187) .001 0.43
Numbers in each analysis vary due to missing data and equalisation of sample size in response to breaches of
the homogeneity of variance–covariance assumption.

Table 4 Problem eaters and

Observed behaviour (% of Comparisons Problem eaters F (df) p Cohen’s d
comparisons on observational
intervals)
measures
N M (SD) N M (SD)

Child positive 33 81.72 (13.62) 74 64.19 (22.54) 15.93 (1104) <.001 0.87
Child negative 33 18.33 (13.87) 74 33.90 (22.63) 12.80 (1104) .001 0.77
Parent positive 33 70.53 (19.84) 74 70.51 (17.81) 0.00 (1105) .995 0.00
Parent negative 33 0.50 (1.57) 74 0.67 (1.26) 0.35 (1105) .557 0.13

using a stringent p value of .01 and t-values for which equal
variances were not assumed where homogeneity of variance
was breached. The descriptive and inferential statistics for
items that differed by group are detailed in Tables 5 and 6.
Among these, parents of problem eaters reported more
frequently distracting, promising food or tangible rewards,
and coaxing their child to encourage eating, and were more
likely to offer alternative food and/or milk after the meal if
the child ate poorly. Parents in this group reported eating
with their child, using mealtime rules, or providing appro-
priate food choices less often than controls, and more fre-
quently berating and force-feeding. In terms of cognitions,
parents of problem eaters more often endorsed items related
to mealtime stress, fears about the consequences of poor
eating (e.g., on weight, health, development), and parental
disagreement over mealtimes. These parents were also more
likely to attribute feeding issues to deliberate actions of the
child, to worry about preservatives and additives, to feel
alone and ineffective in managing mealtime issues, and to
perceive fewer supports.
No significant main effect was found for observed
mealtime parent behaviour, F(2104) = 0.17, p = .842 (see
Table 4). Mean rates of each composite were very similar in
each group, and observed negative behaviours rare.
General Parenting Variables
A significant main effect was found for the MANCOVA
comprising general parenting style (PS) and self-efficacy
(PTC), F(3185) = 16.35, p < .001. Follow-up univariate
comparisons indicated no significant differences between
the groups on general parenting style, yet lower general
J Child Fam Stud (2017) 26:3167–3178 3173

Table 5 Parent strategy items on the PATFA that differed by group (p < .01)
Item Comparisons Problem eaters t (df)
(N = 103) (N = 96)
M (SD) M (SD)

Eating with your child 4.52 (0.74) 4.11 (1.06) 3.15 (168.85)
Offering something else to your child if he/she doesn’t eat the food 2.24 (1.03) 2.79 (1.25) −3.39 (197)
provided
Promising your child a food reward (e.g., a treat/dessert/favourite food) if 2.17 (1.10) 3.11 (1.31) −5.49 (197)
he/she isn’t eating well
Distracting your child (e.g., with games, TV, toys) to get him/her to eat 1.91 (1.08) 2.51 (1.26) −3.59 (187.65)
Promising your child a toy or activity (e.g., game, TV time, or outing) if 1.62 (0.91) 2.35 (1.27) −4.64 (170.79)
he/she isn’t eating well
Giving your child a bottle or milk after an unfinished meal to make sure 1.68 (0.97) 2.24 (1.28) −3.46 (177.03)
he/she gets enough
Coaxing and pleading with your child to eat more 2.18 (0.96) 3.50 (1.14) −8.77 (185.89)
Setting a goal with your child for how much they will eat 2.13 (1.24) 2.78 (1.39) −3.49 (197)
Threatening your child with consequences for not eating or misbehaving at 1.93 (0.99) 2.45 (1.24) −3.23 (182.04)
mealtimes
Allowing your child to decide when he/she has eaten enough 4.08 (1.06) 3.58 (1.06) 3.28 (197)
Providing your child with appropriate food choices at mealtimes 4.50 (0.87) 4.11 (0.92) 3.04 (197)
Yelling at or scolding your child for not eating or misbehaving at mealtimes 1.89 (0.83) 2.29 (1.08) −2.90 (177.36)
Having a set of rules around what behaviours are expected at mealtimes 3.97 (1.23) 3.47 (1.38) 2.67 (190.48)
Physically forcing food into your child’s mouth if he/she refuses to eat 1.15 (0.41) 1.42 (0.87) −2.83 (132.73)
Scale: 1 (Never)–5 (Almost Always); t = independent samples t-test

parenting self-efficacy among parents of problem eaters.
Excluding two eating-specific items from the PTC Beha-
viour scale (Your child refuses to eat their food, Your child
takes too long when eating) in order to limit the influence of
problem eating on the overall parenting self-efficacy score
did not alter findings, differences between the groups on the
PTC Behaviour scale remaining significant, F(1187) =
20.26, p < .001. Means on the PTC Behaviour scale were
close to clinic means for the feeding difficulties group,
while PS scale means for both groups were within normal
limits and PTC Setting scale means close to community
means.
General Child Behaviour
ECBI scores were also found to differ by group, F(2180) =
5.73, p = .004. Follow-up ANCOVA indicated significant
differences on the Problem scale, with parents of problem
eaters reporting a greater number of disruptive child beha-
viours than non-problem eaters, though the reported fre-
quency of these behaviours (Intensity scale) did not differ
by group. Subtracting items relevant to eating (Dawdles or
lingers at mealtimes, Has poor table manners, Refuses to
eat food presented) resulted in a non-significant omnibus
MANCOVA, F(2180) = 2.52, p = .083, though a similar
pattern of significant group differences on the Problem but
not Intensity scale was suggested by univariate analysis.
Table 3 shows the means for both groups were within
normal limits.
Predictors of Feeding Difficulties
A hierarchical regression was conducted on the total sample
to examine the relative importance of child and parenting
factors in predicting child feeding difficulties. The overall
model, significantly predicted problem eating, F(1146) =
33.22, p < .001, accounting for 69.50% of the variance in
child feeding difficulties. Results are displayed in Table 7.
Child age was mildly correlated with feeding concerns
(r = .373, p < .001) and predicted problem eating in the
overall model, R2 = .14, F(1155) = 25.05, p < .001. Parent
mealtime self-efficacy and cognitions likewise contributed
significantly to prediction, ΔR2 = .39, F(3149) = 63.34,
p < .001, with more frequent feeding issues associated
with more unhelpful cognitions about mealtimes (r = .740,
p < .001) and lower parental self-efficacy about feeding
(r = −.742, p < .001). General disruptive child behaviour
(r = .384, p < .001) and maladaptive parenting mealtime
strategies (r = .297, p < .001) were each mildly correlated
with and predicted problem eating at their respective steps
but did not remain significant predictors in the overall
model. General parenting style and self-efficacy failed to
contribute significantly to the prediction of feeding issues,
ΔR2 = .00, F(3146) = 0.47, p = .701.
3174 J Child Fam Stud (2017) 26:3167–3178

Table 6 Parent cognition items on the PATFA that differed by group (p < .01)
Item Comparisons Problem eaters t (df)
(N = 104) (N = 96)
M (SD) M (SD)

It is a struggle to get my child to eat 1.75 (0.86) 3.85 (1.04) −15.40 (198)
If I didn’t guide or regulate my child’s eating, he/she would eat the wrong 3.37 (1.02) 4.16 (0.87) −5.87 (196.84)
amount or types of foods
My child would eat a lot better if I just knew how to manage him/her at 2.02 (0.83) 3.55 (1.00) −11.64 (184.81)
mealtimes
Feeding my child is much harder than I thought it would be 2.18 (0.96) 3.99 (0.84) −14.01 (196.84)
I feel stressed out during mealtimes with my child 1.99 (0.89) 3.73 (1.08) −12.36 (184.19)
I enjoy mealtimes with my child 4.01 (0.84) 2.89 (0.96) 8.77 (189.53)
When my child misbehaves at mealtimes, I feel like he/she is doing it on 2.31 (0.89) 2.69 (1.03) −2.79 (198)
purpose
I feel anxious when my child does not finish their meal/snack 2.17 (0.97) 3.29 (1.01) −7.96 (198)
I feel like I am the only parent facing these problems 1.55 (0.68) 2.03 (1.00) −4.02 (198)
As long as my child eats something, I don’t care what it is 1.67 (0.72) 1.96 (0.79) −2.67 (198)
I feel defeated by my child 1.68 (0.77) 3.04 (1.09) −10.09 (168.61)
I worry that my child is underweight 1.77 (0.88) 2.52 (1.23) −4.89 (171.26)
I feel like I spend the whole meal so focused on what and how my child 2.02 (0.89) 3.31 (1.06) −9.30 (186.40)
eats, I don’t get to enjoy it
I feel confident that my child eats enough 4.20 (0.93) 2.83 (1.04) 9.77 (190.69)
I worry about my child not growing or developing properly 1.88 (1.01) 2.91 (1.14) −6.68 (190.01)
I worry about my child’s health 2.36 (1.04) 3.38 (1.10) −6.74 (198)
I am unsure what to do when my child refuses to eat 2.20 (0.90) 4.13 (0.68) −17.13 (191.41)
I have to be careful what I feed my child because of all the preservatives 3.31 (1.23) 2.82 (1.26) 2.75 (198)
and additives in food nowadays
I worry that my child’s diet lacks variety 2.37 (0.95) 4.05 (1.01) −12.18 (198)
If my child does not eat well, I feel like I’m a bad parent 2.27 (1.02) 3.18 (0.96) −6.45 (198)
I have friends and family I can ask for advice on feeding 3.89 (0.68) 3.13 (1.09) 5.94 (157.23)
My child’s behaviour at mealtimes upsets my partner# 2.38 (1.08) 3.49 (1.22) −6.58 (184)
I get upset with the way my partner deals with our child at mealtimes# 2.26 (0.98) 2.68 (1.07) −2.85 (184)
Scale: 1 (strongly disagree)–5 (strongly agree)
Analyses for these items were based on N = 98 and N = 88 respectively due to missing data t = Independent samples t-test
#

Discussion Valente et al. 2007). Parent mealtime strategies further

The current study identified a number of factors differ-
entiating children and families with mealtime difficulties
from comparisons. Of primary interest were parent factors,
including parent mealtime practices given the role of par-
enting in problem eating (Crist and Napier-Phillips 2001;
Sanders, Patel, et al. 1993). We found parents of problem
eaters to report less adaptive mealtime practices, consistent
with predictions. Parents of problem eaters reported more
frequent use of unhelpful strategies overall, and in particular
distracting, coaxing, berating, force-feeding, and offering
alternative foods more often, and less frequently eating with
the child, using mealtime rules and providing food choices,
strategies which have been associated with problem eating
in the literature (e.g., Crist and Napier-Phillips 2001; Orrell-
predicted child problem eating when introduced in the
regression, though did not remain a significant predictor
once other variables were introduced.
Only parent mealtime cognitions, including mealtime-
specific parental self-efficacy, predicted child feeding in the
final model, which included a number of child and parent
factors. This suggests that cognitions may be particularly
salient in explaining child problem eating, and may repre-
sent key targets for intervention (Morawska and Sanders
2007). In the current study, this included concerns about the
potential impact of poor eating on the child, attributions of
problem eating to being a ‘bad parent’ and/or deliberate
actions of the child, and feeling alone in managing mealtime
issues. This extends the emerging literature on how parents
think and feel about mealtimes.
J Child Fam Stud (2017) 26:3167–3178 3175

Table 7 Hierarchical multiple

Predictor β 95% Confidence interval for β t p r sr2
regression analysis predicting
child feeding difficulties from Lower bound Upper bound
child and parent variables
Step 1
Child age 0.37 0.23 0.52 5.01 <.001 .373 .139
Step 2
Child age 0.24 0.08 0.39 2.90 .004 .373 .139
ECBI Intensity scale 0.21 0.02 0.40 2.12 .036 .384 .147
ECBI Problem scale 0.12 −0.07 0.32 1.26 .211 .362 .131
Step 3
Child age 0.31 0.15 0.46 3.91 <.001 .373 .139
ECBI Intensity scale 0.15 −0.03 0.33 1.62 .107 .384 .147
ECBI Problem scale 0.10 −0.08 0.28 1.06 .292 .362 .131
Parent mealtime strategies 0.31 0.17 0.44 4.34 <.001 .297 .088
Step 4
Child age 0.20 0.09 0.30 3.68 <.001 .373 .139
ECBI Intensity scale 0.02 −0.10 0.15 0.33 .741 .384 .147
ECBI Problem scale −0.03 −0.15 0.10 −0.41 .683 .362 .131
Parent mealtime strategies 0.02 −0.08 0.12 0.43 .669 .297 .088
Parent mealtime cognitions 0.40 0.27 0.53 6.00 <.001 .740 .548
Parent mealtime self- −0.39 −0.52 −0.26 −5.97 <.001 −.742 .551
efficacy
Cognitions about partners 0.06 −0.05 0.17 1.11 .268 .456 .208
Step 5
Child age 0.21 0.10 0.33 3.60 <.001 .373 .139
ECBI Intensity scale 0.03 −0.10 0.17 0.46 .650 .384 .147
ECBI Problem scale −0.01 −0.15 0.12 −0.21 .835 .362 .131
Parent mealtime strategies 0.03 −0.08 0.14 0.59 .554 .297 .088
Parent mealtime cognitions 0.40 0.27 0.54 5.90 <.001 .740 .548
Parent mealtime self- −0.41 −0.56 −0.26 −5.25 <.001 −.742 .551
efficacy
Cognitions about partners 0.06 −0.05 0.17 1.16 .249 .456 .208
PS Total score −0.03 −0.15 0.09 −0.46 .645 .196 .038
PTC Behaviour scale 0.08 −0.09 0.25 0.90 .368 −.471 .222
PTC Setting scale −0.05 −0.19 0.09 −0.73 .465 −.228 .052
β beta, t t-test

Ratings of parental self-efficacy related to feeding were
poorer among parents of problem eaters. This is consistent
with anecdotal evidence suggesting parents of problem
eaters feel ineffectual in feeding their children (e.g., de
Moor et al. 2007a), and established this empirically. Parents
of problem eaters also rated themselves as less competent in
managing other child behaviours (e.g., tantrums, interrupt-
ing) and settings (e.g., bathing, shopping). This finding is in
contrast to previous research which found general parental
self-efficacy similar among parents of problem eaters and
controls (Dunne et al. 2007; Sanders et al. 1997). We
applied a task-specific measure of parental self-efficacy
rather than using a tool which seeks more global ratings of
parenting self-efficacy, which likely provided a closer
estimate of behaviour (Bandura 1997). This would suggest
that parents of problem eaters feel less effective not only at
mealtimes but at various other parenting tasks. We did not
control for levels of problematic child behaviour by group
when comparing self-efficacy, though our problem eaters
group did not appear to have more problematic behaviour
generally—while parents of problem eaters did report a
greater number of child behaviours as problematic, these
were not more frequent than comparisons nor were scores
above clinical cut-offs. Other research has found more
behavioural difficulties amongst children with feeding
issues (e.g., Sanders, Patel, et al. 1993; Sanders et al. 1997)
though in each case, as in the current study, disruptive
behaviour was below clinical levels. This would suggest
3176
that, while broader behaviour may well be of concern to
parents, problem eating remains the primary challenge.
Likewise, general parenting style did not differ by group
with mean ratings within normal limits, suggesting that
parents of problem eaters did not identify more problematic
styles of parenting than their non-problem eater counter-
parts. The lack of generalisation of parent and child meal-
time behaviour may support intervention with mealtime
difficulties specifically rather than more broadly. In regards
to the generalisation of mealtime-specific self-efficacy to
other tasks of parenting, it is possible that parents encoun-
tering mealtime issues feel less effective at parenting more
generally, consistent with the bidirectional nature of self-
efficacy (Bandura 2001), though the direction of associa-
tions here is unclear.
In the current study, a greater proportion of problem
eaters had a history of difficulties with breastfeeding and the
transition to solids. This is consistent with evidence of a
trajectory between infant and later eating issues (e.g., Dahl
and Sunderlin 1992; Farrow and Blissett 2012) and would
support early detection of and intervention for feeding
problems. Data on the stability of eating behaviours over
time is however generally sparse, and little is known about
how such chronicity relates to other constructs, for example,
parental self-efficacy. Clearly early feeding issues also need
to be considered in conjunction with other factors, given
that this described less than half of problem eaters.
Limitations
Several limitations of the study are apparent. First, the
sample was a reasonably homogenous group of educated
mothers in intact marital relationships, who had volunteered
to participate. While various avenues of recruitment were
used, only a small number of fathers, single parents and
other family types participated. While this limits the con-
clusions that can be drawn about fathering at mealtimes, the
absence of fathers in our sample is reflected in the child
development literature generally (Phares et al. 2005) and the
feeding literature more specifically (Owen et al. 2010). This
is despite evidence that fathers are increasingly involved in
childrearing and mealtimes (Snethen et al. 2008), and the
unique and important influence of fathers on child weight
(Fraser et al. 2011). Further remains to be explored
empirically on the potentially differential role of mothers
and fathers in problem eating, and with a broader sample
generally, to ensure adequate generalisability.
The focus on healthy, typically developing children was
consistent with the study’s aims in contributing to literature
on feeding issues in this population. Target children varied
in age from 1.5 to 6 years; while this may be considered a
heterogeneous age range, it was intended to represent the
preschool period, during which feeding difficulties
J Child Fam Stud (2017) 26:3167–3178
frequently emerge (de Moor et al. 2007b), and in fact 90%
of the sample were aged 4 years and under. That problem
eaters were on average older than controls in the current
study may be intuitive as eating becomes more autonomous
with age, though extant research has suggested both more
problematic feeding in the early years due to developmental
constraints (Sanders, Patel, et al. 1993) and in older child-
hood owing to the chronicity of concerns (Koivisto and
Sjoden 1996). The current study chose to control for age in
conducting analyses, though feeding by age and the influ-
ence of parenting and other factors in this context requires
further research attention.
We acknowledge limitations in the use of parent self-
report data generally, and particularly at a single time point
which raises concern of common method variance as an
explanation for relationships between variables. We
attempted to minimise this by using established ques-
tionnaires to ensure construct validity, and various scale
types and formats to provide methodological separation.
The PATFA is a more recent measure, though child
feeding on the PATFA was correlated with observed
child mealtime behaviour. Use of the PATFA further
reflected the absence of a measure appropriate for measur-
ing multiple domains (child and parent) related to mealtimes
with younger children. The PATFA has now been used in
several studies (e.g., Adamson et al. 2013; Morawska et al.
2014) with promising psychometric properties, and is the
subject of a paper in preparation (Adamson and Morawska
2016).
Finally, observational data did not differentiate parents of
problem eaters from controls; aversive parent behaviour
was rare, and means for positive strategies similar by group.
This may have been the result of observer reactivity, despite
research assistants not being present during filming. Fre-
quency coding methods, such as the MOS, also provide
limited information on how strategies are used (e.g., praise
after good behaviour vs. pre-emptive praise). The interrater
reliability obtained for the MOS was lower than reported in
other studies, though interrater correlations were moderate
to high. Several of the videos for the problem eaters group
were rated as atypical even on the second observation
attempt; all were more typical on the second attempt though
and any divergence positive (e.g., the child behaving better
than usual) which may in fact provide a more conservative
estimate of group differences. That all observations for the
comparison group were rated as typical on the first attempt
is interesting in itself, and perhaps suggests greater varia-
bility in the mealtimes of families with feeding difficulties.
Notwithstanding these limitations, the current study pro-
vides evidence for the role of parenting factors, particularly
parental cognitions, in childhood problem eating and so
directions for assessment and intervention.
J Child Fam Stud (2017) 26:3167–3178
Acknowledgements The Parenting and Family Support Centre is
partly funded by royalties stemming from published resources of the
Triple P – Positive Parenting Program, which is developed and owned
by The University of Queensland. Royalties from the program are also
distributed to the Faculty of Health and Behavioural Sciences at UQ
and contributory authors of Triple P programs. Triple P International
(TPI) Pty Ltd is a private company licensed by Uniquest, Pty Ltd, a
commercialization company of UQ, to publish and disseminate Triple
P worldwide. The authors of this report have no share or ownership of
TPI. Dr Morawska has received royalties from TPI. TPI had no
involvement in the study design, collection, analysis or interpretation
of data, or writing of this report.
Author Contributions M.A. designed and executed the study,
analysed the data, and wrote the paper in collaboration with A.M.
Compliance with Ethical Standards
Conflicts of Interest The authors declare that they have no com-
peting interests.
Ethical Approval All procedures performed in studies involving
human participants were in accordance with the ethical standards of
the institutional and/or national research committee and with the 1964
Helsinki declaration and its later amendments or comparable ethical
standards.
Informed Consent Informed consent was obtained from all indivi-
dual participants included in the study.
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