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The Children's Eating Behavior Inventory: Reliability and Validity Results

Article  in  Journal of Pediatric Psychology · November 1991

DOI: 10.1093/jpepsy/16.5.629 · Source: PubMed

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Journal of Pediatric Psychology. Vol. 16, No. 5. 1991. pp. 629-642

The Children's Eating Behavior Inventory:

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Reliability and Validity Results1
Lynda A. Archer,2 Peter L. Rosenbaum and David L. Streiner
McMaster University

Received June 5. 1990; accepted November 7. 1990

Eating and mealtime problems are common in childhood. They occur across a
broad age span, in normally developing children and in a wide variety of devel-
opmental and medical disorders. There is no currently available standard instru-
ment by which to assess these problems. The Children's Eating Behavior In-
ventory (CEBI) was developed according to a conceptual framework based upon
a transactionallsystemic understanding of parent-child relationships. It was
completed by 206 mothers of nonclinic children and 110 mothers of clinic chil-
dren. Results of test-retest and internal reliability testing indicate that the CEBI
meets criteria for instrument reliability. Construct validity is demonstrated by
the significant difference between the clinic and nonclinic groups in the mean
total eating problem score and in the mean number of items perceived to be a
problem.

KEY WORDS: eating behavior, children; assessment.

'The research described herein is supported by a grant from the Hospital for Sick Children Founda-
tion (#XG 89-004) awarded to Lynda A. Archer. Appreciation is expressed to many individuals
including several family physicians in the Hamilton-Wentworth area, members of the Departments
of Pediatrics and Psychiatry at Chedoke-McMaster Hospitals, Oded Bar-Or and Mike Brown of the
Children's Exercise and Nutrition Clinic, many staff from the Children's Developmental Rehabilita-
tion Centre, clinical nutritionist Diane Pirhonen, the Infant-Parent Program at Mississauga Hospi-
tal, and the Phenylketonuria Clinic at the Hospital for Sick Children, Toronto. Special thanks to
Charles E. Cunningham for his conceptual assistance in the early stages of the project and to Lisa
Buckingham for her excellent data management and statistical analyses.
2
A11 correspondence should be addressed to Lynda A. Archer, Department of Psychology, Chedoke
Child and Family Centre, Evel 1, Chedoke-McMaster Hospitals, Hamilton, Ontario L8N 3Z5,
Canada.
629
0146-8693/9I/I00O-O629S06.50/0 © 1991 Plenum Publishing Corporation
630 Archer, Rosenbaum and Streiner

Eating and mealtime (E/M) problems in childhood are common in both clinic
and nonclinic populations. Palmer, Thompson, and Linscheid (1975) estimated
that 25 to 35% of children referred to an outpatient pediatric clinic had recog-
nized or reportable eating problems. Similar figures have also been suggested for
nonclinic populations (Hertzler, 1983). Linscheid (1983) suggested that the prev-
alence may be significantly higher in clinic groups both because parents fail to
report eating problems when another more pervasive disorder is present and
because clinicians fail to identify them. Because E/M problems are "functional"

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rather than "medical" they are often not perceived as falling in the medical
realm. These functional eating problems are often the consequence of therapeutic
decisions such as the need for increased frequency of feeding or special dietary
management. They may derive from parental worry or fear of inadequate nutri-
tional intake in an ill child, and thereby result in an undue focus on the volume
and/or mechanical aspects of feeding. Whatever their origins, such problems
commonly accompany childhood illnesses, and may be considered generic diffi-
culties because they are not specifically and primarily medical. They may be
missed by health professionals addressing the major diagnostic disorder while
neglecting these vital components of the daily interaction of child and care-
giver.
The assessment and treatment of E/M problems has been highly variable
reflecting the involvement of a wide variety of disciplines and the absence of an
overall conceptual framework and classification system from which to view these
problems (Dahl & Sundelin, 1986). A major issue in the area has been the
absence of a standardized assessment instrument. Case reports and anecdotal
comments indicate that the day-to-day management of childhood E/M problems
can be highly stressful to parent-child interactions and to family functions over-
all (Archer, Cunningham, & Whelan, 1988; Archer & Szatmari, 1990; Chatoor,
Conley, & Dickson, 1988; Hagekull & Dahl, 1987). An instrument that could
screen for E/M problems, provide an objective assessment of the type and
severity of the problem, and provide a measure of the degree of stress to the
caretaker would represent a significant advance in the field.
The Children's Eating Behavior Inventory (CEBI), a parent-report instru-
ment, is conceptually derived from a transactional/systemic approach to child-
hood eating and mealtime problems (further discussion of such an approach to
these problems is given in Archer, 1990). The CEBI is intended to assess E/M
problems across a broad age span and in a wide variety of medical and develop-
mental disorders. We endorse Linscheid's (1983) proposal that childhood E/M
disorders be regarded as a separate clinical entity regardless of medical
diagnosis.
Children's Eating Behavior Inventory 631

METHOD

Questionnaire Construction

Item Selection and Content. Items for the CEBI were generated by col-
leagues familiar with children with E/M problems and from descriptions in the
literature of children's E/M problems. In addition, inclusion of items in the CEBI
was guided conceptually by the intent of the instrument to (a) reflect the contri-

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bution of child, parent, and family factors to E/M problems, (b) be applicable
across a broad age span, and (c) be useful in a variety of developmental and
medical conditions (Streiner & Norman, 1990). The CEBI has 40 items (see
Appendix). Phi-coefficient analyses of data from the first version resulted in a
reduction of the item pool from 71 to 40 items (Archer & Cunningham, 1988).
The items can be grouped into two broad categories: items pertaining to the
child, and items pertaining to the parent and family system. The 28 items in the
child domain are intended to assess food preferences, motor skills, and behav-
ioral compliance. The 12 items in the parent domain are intended to assess
parental child behavior controls, cognitions and feelings about feeding one's
child, and interactions between family members. Two skip patterns were devel-
oped to permit the inclusion of single-parent families and families with only one
child. Single parents skip four items leaving a total of 36 items. Two-parent
families with only one child skip one item leaving a total of 39 items. In these
cases a weighting system was devised to compensate for the omitted items.
Item Scaling and Scoring. For each item, the respondent indicates on a 5-
point Likert response scale how often the behavior occurs (i.e., never, seldom,
sometimes, often, always). Twenty-eight items are scored positively, 12 items are
scored in the negative direction. The respondent also records whether she per-
ceives an item to be a problem by answering Yes or No to the question "Is this a
problem for you?" Two scores are derived from the instrument. The total eating
problem score is obtained by adding the scores for each item (the highest possible
score is 5 for each item). The total number of items perceived to be a problem is
determined by adding the number of "Yes" responses to the question "Is this a
problem for you?"

Subjects

All cases were recruited by consecutive case procedures. The 110 clinic
(CL) subjects came from outpatient pediatric and mental health clinics. The 206
subjects in the nonclinic group (NCL) were normally developing children re-
 632 Archer, Rosenbaum and Streiner

cruited from 11 community family physicians' offices in the Hamilton-Went-

worth Region. This was deemed the most parsimonious manner of recruiting a
large number of children across a broad age span, including both preschool age
and school age children. To provide for educational and socioeconomic diversity
in the nonclinic subjects an effort was made to approach physicians practicing in
different parts of the region. However, this was not done in any systematic
manner.
Inclusion criteria for the clinic cases were (a) children 2.0 to 12.11 years of

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age, (b) children referred for assessment and treatment of an identified eating
problem, and (c) children with developmental or medical disorders likely to
place them at risk for E/M problems as determined from clinical experience and
reports in the literature. The six children in the identified eating problem group
had a variety of diagnosesincluding nonorganic failure to thrive (n = 1), specific
language disorder (n = 1), food refusal (n= 1), and mental retardation (n = 3).
All had been referred for assessment and treatment of E/M problems. Subjects in
the "at risk" clinic group included obese (n = 30), autistic (n = 9), physically
disabled (n = 46), mentally handicapped (n = 11), phenylketonuric (n — 7), and
Prader-Willi (n = 1) children. To be considered obese, subjects were above 30%
body fat as determined by body underwater weighing (Lohman, 1986). Subjects
with obesity in the presence of another medical or developmental disorder (e.g.,
cerebral palsy, cystic fibrosis) were excluded. Children in the autistic group came
from an ongoing study of autistic children. With the exception of 6 cases who
were autistic but had IQs below 68, all were higher functioning autistics (IQ
above 68) who met DSM-III-R criteria for Pervasive Developmental Disorder
(American Psychiatric Association, 1987). Children in the physically disabled
group had been referred to a local children's rehabilitation center and included
primarily children with cerebral palsy and spina bifida. Children in the mentally
handicapped group were recruited from centers or programs for the developmen-
tally handicapped.
Twenty-four cases (7%) were excluded from the data analyses due to spoiled
questionnaires. Of these, 13 came from the clinic group and 11 from the non-
clinic group. Because subjects were obtained from several different clinics and
programs simultaneously, this precluded having a research assistant on site for
questionnaire administration. Therefore, it was not possible to systematically
monitor the number of times the CEBI was refused. However, anecdotal reports
from both clinic and nonclinic sources indicated that the CEBI was well received
and that there were almost no refusals. In the small number of instances when it
was refused this seemed to be related less to the CEBI than to the fact that the
mother had already been approached to participate in several other projects.
Demographic information for both groups is given in Table I. Analyses of
variance and / tests showed that the groups did not differ on any of a large
number of demographic variables including sex and age of the child, parental
age, marital status and education, family size, mother's history of eating prob-
Children's Eating Behavior Inventory 633

Table I. Demographic Information for CLinic and Nonclinic Groups

Nonclinic Clinic
(n == 206) (n = 110)

Variable n % n %

Child
Male 104 51 61 55
Female 102 49 49 45
Mean age (years ± SD) (5.9 :t 3.10) (7.1 ± 3.32)

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Family
Single parent 36 18 18 16
Only child 41 20 17 16
Maternal self-report of eat-
ing problems 63 31 33 30
Mother's education
Some secondary or less 42 20.8 18 17.0
Secondary 64 31.7 42 39.6
College 58 28.7 34 32.1
University 38 18.8 12 11.3
Father's education
Some secondary or less 35 20.8 22 25.3
Secondary 52 31.0 24 27.6
College 39 23.2 23 26.4
University 42 25.0 18 20.7

lems as a child. Maternal history of an eating problem was determined by the

mother's yes/no response to the question, "Have you yourself ever had any
eating/mealtime problems."

Procedure

The CEBI, including the demographic questions and a cover letter explain-
ing the project, took approximately 15 minutes to complete. A detailed instruc-
tion sheet telling the respondent how to complete the questionnaire was also
used. All questionnaires were completed by mothers. The instructions for moth-
ers of the nonclinic subjects included an additional instruction that they fill out
the CEBI for their youngest (or oldest) child between 2 and 12 years, if they had
more than one child. In other words, 50% of the CEBIs said youngest child; 50%
said oldest child. This procedure was taken to prevent the parent from choosing
to complete the form either for a child who did have some eating problems or for
a child who ate particularly well. The questionnaires were completed as part of a
routine clinic visit. Both clinic and nonclinic subjects were approached by their
physician or clinic therapist after instructions from the research personnel about
how to present the questionnaire. To control for selection bias, clinicians were
instructed to offer the CEBI to all mothers, even those whom they thought might
refuse to do it.
634 Archer, Rosenbaum and Streiner

A retest was done for both clinic and nonclinic subjects 4 to 6 weeks after
the first administration. Cases were chosen by consecutive case procedures.
Some cases were not eligible to participate because the form was returned outside
the 4- to 6-week time span. After obtaining telephone consent a second CEBI
was mailed. Subjects were telephoned approximately 1 week after the mailing.
Test-retest reliability was determined both for the total eating problem score and
for the number of items perceived to be a problem. All mothers approached about
the retesting agreed to participate and the return rate was 100%.

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To assess internal consistency of the CEBI, Cronbach alphas were com-
puted. Because of missing data resulting from the skip pattern provided for single
parents and families with one child, separate alpha coefficients were determined
for (a) two parent/two children cases, (b) two parent/only child cases, (c) single
parent/only child cases, and (d) single parent/two children cases. An alpha level
of .05 was considered significant for all data analyses.
Construct validity of the CEBI was derived from comparisons of the CEBI
scores for the clinic group versus the nonclinic group. It was hypothesized that
the total eating problem score would be higher for the clinic group and that the
number of items perceived to be a problem would be greater for the clinic group.
It was also predicted that, by virtue of their earlier developmental level in terms
of motor and social/behavioral skills, the scores would be higher for younger
children (2 to 6 years old) as compared with older children (7 to 12 years old).
Because there are no other comparable existing instruments it was not possible to
assess concurrent validity of the instrument at this time.
To assess the distribution of children with E/M problems across the different
groups, the data for each group were put into box plot graphs. Box plots provide
a graphic presentation of data in which a variety of indices of central tendency
and dispersion can be observed at one time for one or more groups. (The reader is
referred to Tukey, 1977, for a more detailed discussion of box plots.)

RESULTS

Test-Retest Reliability

Test-retest reliability was determined for 38 cases (28 clinic and 10 non-
clinic) 4 to 6 weeks (mean 33 days) after the initial completion. The intraclass
correlation coefficient was .87 for the total eating problem score, and .84 for the
percentage of items perceived to be a problem.

Internal Consistency

The coefficient alpha's for the different subgroups are shown in Table II. All
of these are within acceptable limits (i.e., above .70) with the exception of the
single parent/more than one child group which is markedly lower at .58.
Children's Eating Behavior Inventory 635

Table II. Internal Reliability Coefficients for Different Subgroups,

Clinic and Nonclinic Subjects Combined

Group n Cronbach's Alpha

Two parents/two or more children 189 .76

Two parents/one child 34 .71
Single parent/one child 15 .76
Single parent/two or more children 28 .58

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Construct Validity

The total eating problem scores are significantly higher, F (1, 314) =
21.19,^ < .0001, for the clinic group (Table III). Mothers of clinic children also
reported a significantly higher proportion, t (311) = 4.42, p < .0001, of the
items to be a problem (Table III). The mean age for the clinic and nonclinic
groups is different with the clinic group being approximately 1 year older, al-
though this did not reach statistical significance. An analysis of covariance was
done with age as the covariate. There was no difference in the total CEBI scores
between the younger (2 to 6 years) and older (7 to 12 years) children either
between groups or within groups (Table III).
Based on the mean percentage of items perceived to be a problem (i.e., 20%
for the clinic group and 13% for the nonclinic group), the midpoint between the
two values (16%), was taken as the cutoff point for defining the presence of an
eating problem. The number of cases for which 16% or more of the items were
perceived to be a problem was significantly greater for the clinic group as
compared with the nonclinic group (x 2 = 16.79, p < .0001). Fifty-six percent of
mothers of clinic children reported 16% or more of the items to be a problem as

Table III. Total Eating Problem Scores and Percentage of Items Per-
ceived to be a Problem for Clinic and Nonclinic Croups by Age Group

Nonclinic Clinic
{n = 206) (n = 110)

M SD M SD

Eating problem score

Total sample0 86.65 11.54 92.52 12.57
2 to 6 years old 88.08 11.73 93.00 14.27
7 to 12 years old 83.93 10.74 92.07 10.85
Percentage of items per-
ceived to be a problem
Total sample" 13.26 13.26 20.86 16.65
2 to 6 years old 13.40 13.32 19.49 17.84
7 to 12 years old 12.97 13.22 22.14 15.51

°p < .0001.
636 Archer, Rosenbaum and Streiner

Menial Handicap

r
Aullsllc

>
Eating Problem
H ———7—-—

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Physical Hanaicap

60 70 80 90 100 110 120 130

Total Eating Problem Score

Fig. 1. Box plots of total eating problem scores for clinic and nonciinic groups. Key parts of a
box plot include (a) the asterisk in the middle which represents the median of the distribution, (b)
the ends of the box which fall at the upper and lower quartiles such that the middle 50% of the
cases fall within the box, (c) lines coming out the ends, "whiskers," which show the degree of
dispersion in the data, and (d) the small circles beyond the whiskers are outliers. Sample size is
represented in the thickness of the box; larger samples have thicker boxes.

compared with 33% of the mothers of children in the nonciinic group. None of
the identified cases in the nonciinic group had been so identified by the family
doctor.
Box plots of the total eating problem scores for the clinic and nonciinic
groups are given in Figure 1. The results show that children with eating problems
occur in almost all the groups, but with the higher scores and greater numbers of
cases occurring in the mentally handicapped, autistic, and eating problem
groups. The PKU group has very little dispersion in its data and very few cases
with eating problems. Conversely, there is considerable variability in the data
from children with a physical disability.

DISCUSSION

Reliability testing shows that the CEBI is a reliable instrument. Preliminary

comparisons between clinic and nonciinic samples indicating higher scores for
Children's Eating Behavior Inventory 637

the clinic group confirm the construct validity of the CEBI. As well, the CEBI
specifies what the specific eating problems are and how stressful they are per-
ceived to be by the mother. Because E/M problems can be highly disruptive and
distressing to children and families, an instrument that can reliably assess these
problems represents a significant advance in the field. The results confirm pre-
vious reports of the high prevalence of E/M problems in both nonclinic and clinic
samples. In addition, the results show that E/M problems are l'/i times more
common for children from clinic populations. The high rate of eating problems in

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children from the nonclinic sample who had not been referred for treatment
suggest the potential application of the CEBI as a screening tool for children's
eating/mealtime problems.
A surprising finding is that age does not appear to be a relevant factor for the
occurrence of E/M problems. The results from the box plot graphs show that
E/M problems occurred in most groups tested. These findings provide initial
support for the transactional/systemic conceptual orientation from which the
CEBI is derived. In work in progress, the CEBI is being given in conjunction
with measures of child behavior and family functioning. It is anticipated that
these data will help to clarify further the role of parent-child-family interac-
tional factors in relation to the medical condition and/or developmental disorder
of the child in children's E/M problems.
Clinical application of the CEBI with a small number of cases has con-
firmed the ability of the instrument to reflect improvement in E/M problems after
an intervention (Archer & Szatmari, 1990; Archer et al., 1988). The CEBI may
also serve as a companion questionnaire to be given with the Children's Eating
Attitudes Test (ChEAT; Maloney, McGuire, & Daniels, 1988). The ChEAT is
completed by children 8 to 13 years of age and provides a measure of the child's
eating attitudes. Several of the items on the ChEAT are similar or identical to
those on the CEBI.
A possible limitation in the present study is a selection bias in the recruit-
ment of subjects for both the nonclinic and clinic groups. Because we did not
have research personnel present in the community physicians' offices or at all the
pediatric clinics, it is possible that the questionnaire was selectively offered to
more compliant mothers (for both the nonclinic and clinic samples) and, in the
case of the clinic group to mothers of less handicapped children. This could then
serve to underestimate the prevalence of E/M problems as well as depress both
scores that were derived from the CEBI. However, the fact that the rates are
already so high may mean on the other hand that a response set is occurring.
Perhaps E/M problems are being inflated by the presence of another more pri-
mary behavioral/developmental problem in the child and or marital/family prob-
lems. The reason for the very low internal reliability level (alpha = .58) for
single parents with more than one child is not readily apparent.
In future studies we intend to look at the pattern of responding (i.e., specific
638 Archer, Rosenbaum and Streiner

items endorsed) in a variety of clinical groups including juvenile diabetic, au-

tistic, obese, phenylketonuric, Prader-Willi, and physically disabled. These data
may help us clarify the contribution of dietary, behavioral, interactional, and
physical factors to children's E/M problems. In work currently underway, we are
obtaining direct observational data (e.g., videotape recordings) of family dinner
times in conjunction with the CEBI for both clinic and nonclinic cases. The
videotape data will serve as a measure of construct and concurrent validity for the
CEBI as well as providing information about family interactional patterns in

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which a child does and does not have an eating problem.

APPENDIX
CEBI

Child's Name Age / Sex M F

Years Months

HOW OFTEN DOES THIS HAPPEN?

NEV- SEL- SOME- OF- AL-
ER DOM TIMES TEN WAYS
1 2 3 4 5

Is this
a problem
for you?

1. My child chews food 1 2 3 4 5 YES NO

as expected for
his/her age
2. My child helps to set 1 2 3 4 5 YES NO
the table
3. My child watches TV 1 2 3 4 5 YES NO
at meals
4. I feed my child if 1 2 3 4 5 YES NO
he/she doesn't eat
5. My child takes more 1 2 3 4 5 YES NO
than half an hour to
eat his/her meals
Children's Eating Behavior Inventory 639

NEV- SEL- SOME- OF- AL-

ER DOM TIMES TEN WAYS
1 2 3 4 5

Is this
a problem
for you?

6. Relatives complain YES NO

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about my child's
eating
7. My child enjoys eating 2 3 4 5 YES NO
8. My child asks for 2 3 4 5 YES NO
food which he/she
shouldn't have
9. My child feeds 2 3 4 5 YES NO
him/her self as
expected for
his/her age
10. My child gags at 4 YES NO
mealtimes
11. I feel confident my 4 YES NO
. child eats enough
12. I find our meals 4 YES NO
stressful
13. My child vomits at 4 YES NO
mealtime
14. My child takes food 4 YES NO
between meals without
asking
15. My child comes to the YES NO
table 1 or 2 minutes
after I call
16. My child chokes at YES NO
mealtimes
17. My child eats quickly 4 YES NO
18. My child makes foods 4 YES NO
for him/her self when
not allowed
19. 1 get upset when my YES NO
child doesn't eat
640 Archer, Rosenbaum and Streiner

NEV- SEL- SOME- OF- AL-

ER DOM TIMES TEN WAYS
1 2 3 4 5

Is this
a problem
for you?

20. At home my child eats 1 2 3 4 5 YES NO

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food he/shouldn't have
21. My child eats foods 1 2 3 4 5 YES NO
that taste different
22. I let my child have 1 2 3 4 5 YES NO
snacks between meals
if he/she doesn't eat at
meals
23. My child uses cutlery 1 2 3 4 5 YES NO
as expected for
his/her age
24. At friends' homes my 1 2 3 4 5 YES NO
child eats food he/she
shouldn't eat
25 My child asks for food 1 2 3 4 5 YES NO
between meals
26 I get upset when I 1 2 3 4 5 YES NO
think about our meals
27 My child eats chunky 1 2 3 4 5 YES NO
foods
28 My child lets food sit 1 2 3 4 5 YES NO
in his/her mouth
29. At dinner I let my 1 2 3 4 5 YES NO
child choose the foods
he/she wants from
what is served

IF YOU ARE A SINGLE PARENT SKIP TO NUMBER 34.

30. My child's behavior 1 2 3 4 5 YES NO

at meals upsets
my spouse
Children's Eating Behavior Inventory 641

NEV- SEL- SOME- OF- AL-

ER DOM TIMES TEN WAYS
1 2 3 4 5

Is this
a problem
for you?

31. I agree with my YES NO

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spouse about how
much our child
should eat
32. My child interrupts 1 2 3 4 5 YES NO
conversations with my
spouse at meals
33. I get upset with my 1 2 3 4 5 YES NO
spouse at meals
34. My child eats when 1 2 3 4 5 YES NO
upset
35. My child says he/she 1 2 3 4 5 YES NO
is hungry
36. My child says 1 2 3 4 5 YES NO
she/he'll get fat if
she/he eats too much
37. My child helps to clear 1 2 3 4 5 YES NO
the table
38. My child hides food 1 2 3 4 5 YES NO
39. My child brings toys 1 2 3 4 5 YES NO
or books to the table

IF YOU HAVE ONLY ONE CHILD SKIP NUMBER 40.

40. My child's behavior at 1 2 3 4 5 YES NO

meals upsets our other
children

PLEASE CHECK TO SEE THAT YOU HAVE ANSWERED ALL THE ITEMS.

HAVE YOU CIRCLED A YES OR NO FOR EACH ITEM? THANK YOU.

 642 Archer, Rosenbaum and Streiner

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Archer, L., & Cunningham, C. E. (1988). A transactional/systemic model of childhood eating and
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Child Neurology, J0(Suppl. 57), 42.
Archer, L., Cunningham, C. E., & Whelan, D. (1988). Coping with dietary therapy in phe-

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