Playing Board Games as a Feeding Intervention for Children with Developmental Disabilities

Michelle Hayes OTD-S, Tasha Henry OTD-S, Jessica Lopez OTD-S, & Aesha Pandya OTD-S

Nova Southeastern University

Research Design Course: OTD 8262

November 5, 2015

 

Abstract

 

Need: Many children with developmental disabilities demonstrate aversive feeding behaviors, such as food refusal and selectivity. Without intervention, these behaviors can cause malnutrition and have life threatening consequences. Evidence suggests that traditional feeding interventions, involving progressive steps, improve food acceptance and reduce aversive feeding behaviors. Using board games as a feeding intervention incorporates an aspect of play into mealtimes, increasing motivation and engagement. No prior research has been done to explore the results of blending a traditional feeding intervention with a board game for children with developmental disabilities.

 

Objective: The purpose of this study is to research the capability of traditional and modified feeding interventions to improve aversive feeding behaviors in children with developmental disabilities. This research adds to the knowledge about the effectiveness of feeding interventions on aversive feeding behaviors demonstrated by children with developmental disabilities, by comparing mealtime behaviors of child and caregiver before and after 13 intervention sessions.

 

Methods: A comparative study will be conducted using a pretest-posttest design to determine the difference between a traditional and modified feeding intervention. Pretest and posttest data will be collected using the Dyadic Interaction Nomenclature for Eating (DINE), a behavioral coding system that assesses video recordings of typical mealtimes. The interventions are 13-week programs designed to decrease aversive feeding behaviors and increase food acceptance, and include: (1) The control group intervention involves child, caregiver, and occupational therapist to follow a set of encounter rules (progressive steps used to gradually expose the child to a food) until the child has cleared a plate consisting of preferred food, non-preferred food, and new food. (2) The experimental group follows the same encounter rules as the control group, however a modified board game is utilized for the feeding intervention.

 

Key Words: Aversive feeding behaviors, developmental disabilities, food refusal, food acceptance, Dyadic Interaction Nomenclature for Eating (DINE)

 

 

Problem Statement

Children with developmental disabilities often display feeding problems related to aversive feeding behaviors, such as food refusal, during mealtime (Archer, Rosenbaum, & Streiner, 1990; Berlin & Cerezo, 2011; Thoyre et al., 2014). Without intervention, children exhibiting these feeding problems may become malnourished, which may lead to life threatening consequences (Gentry & Luiselli, 2007).

Purpose

Research question. Do board game interventions encourage eating and reduce aversive feeding behaviors during mealtimes for children with developmental disabilities along with feeding problems?

Objectives. Determine the effectiveness of a board game intervention to decrease aversive feeding behaviors and increase eating of preferred, non-preferred, and new foods during mealtime.

Hypothesis. A board game intervention can significantly minimize the severity and frequency of aversive feeding behaviors demonstrated by children with developmental disabilities.

 

Background and Significance

Eating and mealtime complications commonly occur amongst children with developmental disabilities (Archer et al., 1990). Childhood feeding disorders have become a growing concern for caregivers and families whose children's nutritional status and well-being is compromised due to inadequate intake of assorted, nutritional foods (Greer, Gulotta, Masler, & Laud, 2008). Didehbani, Kelly, Austin, and Wiechmann (2011) estimated that 35% of children with developmental disabilities have feeding problems. Aversive feeding behaviors, which include food refusal, choking, gagging, and spitting, have been found in 18% of children with developmental disabilities (Schwarz, Corredor, Fisher-Medina, Cohen, & Robinowitz, 2001). These behaviors can result in a diet restricted of substance and variety (Greer et al., 2008). When this occurs, a child could end up malnourished, and may face other physiological dilemmas, which may become fatal (Gentry & Luiselli, 2007).

The Person-Environment-Occupation-Performance (PEOP) model structures the delivery of the intervention and serves as frame of reference for the proposed research project. The PEOP model states that people are occupational beings, which are influenced by intrinsic and extrinsic contexts (Christiansen & Baum, 2005). The PEOP model emphasizes the role of occupational therapists in motivating, educating, and making adaptations, in order to enable clients to participate in meaningful activities and occupations; such as eating, socialization, and playing (Christiansen & Baum, 2005). This model frames a holistic delivery of treatment and interventions for both caregivers and clients (Christiansen & Baum, 2005). As a critical part of human development, play is considered a meaningful occupation for children and is supported by the PEOP model (Tanta & Knox, 2015; Christiansen & Baum, 2005).

A child can become engaged in mealtime and feeding through play by using board games (Tanta & Knox, 2015). Competitive board games in which the child, therapist, and caregiver cooperatively participate have many benefits, including an improved bond between the therapist and the child (Berlin, 2004; Tanta & Knox, 2015). By age 4, most children can understand rules and the ultimate goal of finishing the game (Berlin, 2004). Children often find playing board games alone to be dull, and prefer to play a game where they can take turns and win the game (Berlin, 2004). The combination of cooperation with the rules and competition to win, provides an intrinsic motivation to perform better (Tauer & Harackiewicz, 2004). Furthermore, board games have been found to increase food acceptance across a variety of food groups and could potentially prove very beneficial for caregivers that struggle with feeding their children, who display aversive feeding behaviors (Gillis, 2003; Gentry & Luiselli, 2007).

Using a pretest-posttest, true experimental design, data will be collected utilizing the Dyadic Interaction Nomenclature for Eating (DINE). The DINE is a behavioral coding system that assesses video recordings of, at least, three typical mealtimes, to observe child behaviors, child eating behaviors, and caregiver behaviors, (Patton, Dolan, & Powers, 2006; Piazza-Waggoner, Driscoll, Gilman, & Powers, 2008; Stark et al., 2000). Utilizing the DINE, researchers will be able to compare a control group and an experimental group before and after intervention.

Experimental design is the highest standard for scientific exploration of causal relationships (Portney & Watkins, 2009). A true experimental design controls most threats to internal validity, as well as selection bias, through a randomized control trial (Portney & Watkins, 2009). The pretest serves as a tool to ensure the groups are equivalent prior to any intervention, thus improving evidence of causal factors (Portney & Watkins, 2009). The posttest, however, can pose as a threat to external validity through the reactive effects of the preceding pretest (Portney & Watkins, 2009). The primary threat to this design is attrition resulting from the time period between pretest and posttest (Portney & Watkins, 2009). The pretest-posttest design would be a strong approach to compare the before and after effects of the experimental group and the control group of this study.

 

Methodology

Study Design

As a true experimental design, this study will use a pretest-posttest control group approach to determine the effectiveness of a modified board game, for the purpose of improving and/or eliminating aversive feeding behaviors in children with developmental disabilities (Gentry & Luiselli, 2008). Using a between subjects (participants), randomized design, fifteen participants will be assigned to the experimental group and fifteen will be assigned to the control group. For the purpose of this study, ‘participant’ refers to the child and their caregiver as a single unit. Each participant will begin with the pretest criteria as soon as they have been recruited. The pretest and posttest will utilize the DINE assessment in order to observe behaviors and changes of the participants in their home environments (Stark et al., 1995, 2000). The DINE assessments will be conducted in the 1st and 15th weeks of the study. The intervention sessions will be conducted in a clinic. The experimental group will be given a feeding intervention, which utilizes a modified board game (Gentry & Luiselli, 2008). The control group will receive a feeding intervention with the same components as the experimental group; however, the modified board game will not be used (Gentry & Luiselli, 2008).

Setting

The pretest and posttest will be administered through the utilization of the DINE assessment. The DINE will consist of three video recorded observations of a typical mealtime within the home, without the presence of a researcher, OT, or other person outside of the typical members of the household that would be present at this time (Stark et al., 1995, 2000). This is to ensure the most accurate demonstration of the participants’ typical mealtime routines and behaviors during the child's feeding (Sanders, Turner, Wall, Waugh, & Tully, 1997).

The intervention sessions will be conducted in a private room of a clinic; which ensures all the participants will undergo the same intervention in the same environment, within their corresponding groups. The environments will also be parallel between experimental and control groups; this will provide uniform treatments for each child at each session.

Sampling Design
            Inclusion criteria.

• Between the ages of 4 and 8 years of age

• Caregiver is experiencing difficulty feeding child

• Clinically diagnosed with a developmental disability

• Physically capable of feeding themselves

• At risk for severe complications or mortality due to malnourishment

            Exclusion criteria.

• Has medical disorders and/or conditions that include food refusal due to swallowing issues, digestion difficulties, severe allergies, or infections

• Sensory processing difficulties

• Diagnosed with Autism

• Diagnosed with an intellectual disability

• Typically exhibits the following behaviors: avoids eye contact, non-verbal, poor motor planning, lack of focus and engagement, unable to connect actions with consequences, and is often emotionally distressed

• Requires total supervision

• Displays difficulty with eye-hand coordination, posture, standing without assistance, sitting without assistance, vision, bilateral coordination, and muscle tone.

• Bothered by tactile stimulation, small sounds, crowds, and cluttered or brightly colored space.

            Participant recruitment and retention. Recruitment will begin following approval from the institutional review board (IRB). Permission will be obtained from facilities to display flyers describing the components of the study along with client incentives (see Appendix A for a sample of the flyer). These facilities may include, but are not limited to, pediatric health care facilities, pediatric outpatient therapy clinics, local community clinics, rehabilitative hospitals, preschools, and elementary schools. Caregivers who are interested in including their children in the study may call the number listed in the flyer to speak with an administrator to be screened for the study. Screening may be conducted over the phone or at the administration office as listed on the flyer (see Appendix B to view the screening tool). Researchers will also recruit participants by conducting or participating in health fairs and other community outreach activities. Researchers may screen potential participants on site. Once the caregivers are screened, and have met the inclusion criteria, they may be accepted as participants and will be given information about the proposed study.

In order to retain participants, monetary and educational incentives will be given to all caregivers upon conclusion of the study. Caregivers who have completed all required posttest materials will be invited to attend an educational workshop on feeding problems, in children with developmental disabilities, led by occupational therapists. This workshop will highlight reasons for behavioral feeding problems, methods of reducing stress associated with difficult mealtimes, and basic nutrition. Educating the caregiver reduces stress and increases the success rate of treatment outcomes in children with developmental disabilities and feeding disorders (Greer et al., 2008). Participants who complete the study will receive $300 at the conclusion of the study. The Foundation of Play will fund incentives, marketing tools, and other financial costs for the purpose of this study.

Participants are able to reschedule session appointments and are provided with different scheduling times to choose from. The time to complete the pretest and posttest materials spans for approximately two weeks, which allows ample time and flexibility. Providing accommodations may help elevate retention levels.

Procedures

Study groups. Following screening, 30 participants, who have met the criteria, will be randomly divided into either experimental or control groups (see Appendix C). Each group, comprised of 15 participants, will be given pretest materials, which include instructions for completing the Dyadic Interaction Nomenclature for Eating (DINE) recordings, during Week 1 and 2. The experimental group and the control group will attend one intervention session per week for 13-weeks between Weeks 2 and 15. At the conclusion of the last intervention, Week 15, caregivers of the experimental and control groups will be issued posttest materials, which includes the DINE. Posttest materials are to be completed by Week 16 (Appendix D).

Pretest and posttest administration. Observation of the child's typical mealtime will be completed using the DINE. The DINE is a coding system that assesses caregiver behaviors, child behaviors, and child eating behaviors during a typical mealtime (Appendix E) (Piazza-Waggoner, Driscoll, Gilman, & Powers, 2008; Stark et al., 2000). To ensure a true observation of a typical mealtime, observations must be done at home without the presence of researchers, occupational therapist, or other persons outside of the typical members of the household (Stark et al., 1995, 2000). This is because the presence of new people or a new environment may make the child less apt to behave in the same manner as usual (Haidet, Tate, Divirgilio-Thomas, Kolanowski, & Happ, 2009).

During the DINE assessment, the caregiver will be instructed to inconspicuously video record three entire typical meal sessions (Stark et al., 2000). Videos will be recorded with any device that records at 8-megapixels or greater (this includes most smartphones). If needed, a video recording device will be loaned to the caregiver to be utilized for the DINE assessment. Researchers will consult caregivers on how to position the camera in order to provide the best angle for recording mealtimes (Powers et al., 2005). Caregivers will also be trained on how to use loaned devices and will have access to technical support, provided by the researchers. Caregivers utilizing their own recording devices will have their devices inspected by researchers to ensure proper video quality, as per the stated criteria. Researchers will also review device functions with the caregivers to ensure they are familiar with the video recording function (Powers et al., 2005). Recordings need to be representative of a typical mealtime; if a caregiver deems a recorded meal as atypical, they will need to record additional mealtimes until they have the required three typical mealtimes (Powers et al., 2005; Stark, et al., 2000). Meals at any time of the day, such as breakfast, lunch, or dinner, may be recorded for submission as long as the meal is deemed typical. Mealtimes should be recorded for the entire time of a typical feeding routine within the household. Meals should consist of foods regularly served in the house.

Caregivers will have a two-week time frame, during the first two and the last two weeks of the study, to complete the DINE assessments (pretest and posttest) (Appendix D). Once the pretest DINE assessment has been completed and submitted to the researchers, the participant may proceed with the first intervention session beginning Week 2. The posttest DINE assessment may be administered any time after the 13th session and is to be completed and submitted no later than the 16th week of the study. Caregivers must submit DINE assessment forms in a sealed envelope provided by the researchers to ensure security. Footage of the recordings must be stored in a secure and password protected flash drive that is placed securely inside the envelope; which the researchers may provide. The alternative is to email the recorded footage to the researchers. The footage and documents may be sent as an attachment within a password protected, encrypted file. Any technical or needed guidance will be provided to ensure security of the data collection and the privacy of the participants.

Treatment administration. Prior to the first intervention, the caregiver will be instructed to complete a food chart (Appendix F), which categorizes foods into the following three categories ‘preferred foods’, ‘non-preferred foods’, and ‘new foods’. Foods categorized as ‘preferred foods’ and ‘non-preferred foods’ must have been presented to the child at least once within the past year. ‘New foods’ include any food that has not been presented to the child within the past year, or has never before been presented to the child. A copy of this list will be kept at home with the caregiver. If needed, the researchers may provide guidance and suggestions in formulating a variety of foods for this list.

The caregiver will be instructed to bring one food serving from each of the three categories; these foods should be from varying food groups (vegetables, proteins, fruit, etc.) (Matthews, Wien, & Sabate, 2011). Caregivers will be instructed not to bring back foods that have been completely refused (during the intervention) for at least two sessions. Any non-preferred foods that the child is making the steps toward trying should be included in at least one more session.

A team of three occupational therapists (OTs) will administer every intervention for both the experimental and control groups. Each OT will be responsible for the intervention sessions of 10 participants (five from the experimental group and five from control group). No more than four participants will be seen each day by any one therapist. Each session will be scheduled on the hour to allow for take down time and breaks. Within a 14-week time period, 13 intervention sessions will be held at an average of one session per week. To allow for flexibility, participants may make-up a missed session within four days, and at least two days before the next scheduled session. During this time period, caregivers will be instructed not to forcefully change mealtime structures outside of the intervention sessions (Patton et al., 2006). Sessions will be held six days a week (Monday through Saturday), for 30-minute intervals. A caregiver will be required to be present for all sessions.

The control group and the experimental group will have similar interventions, designed to improve and/or eliminate aversive feeding behaviors in children with developmental disabilities. At each intervention session, participants will be presented one serving of food from each section of the food chart. The food will be equally divided three ways, so that the occupational therapist, the caregiver, and the child can participate in every intervention. Food items will be placed on sectioned plates to ensure the foods will not touch or mix with each other. The same plates will be provided for every session. The food will be served at the typical serving temperature. A spit-cup and a cup of water will be provided to the participants and the OT. The OTs will provide the same intervention per session per participant, with a goal of clearing the entire plate by the end of the session. The experimental group will require utilization of the same board game for every participant.

In an effort to ease the child’s transition to accepting a new or non-preferred food, both the control group and experimental groups will follow a set of modified encounter rules (Penrod, Gardella, and Fernand, 2012). The encounter rules increase in difficulty at appropriate intervals (Appendix G). The caregiver, the occupational therapist, and the child will take turns following the encounter rules for each food. The child’s compliance with these encounter rules will result in verbal praise along with a high five, pat on the back, or other positive reinforcement (Patel et al., 2007).

The experimental group will use the modified board game as a feeding intervention; which is played by the OT, the child, and the caregiver (Gentry & Luiselli, 2008). The board game is comprised of a path of 30 color-coded, patterned squares of red, blue, and green; each corresponding to a particular category from the food chart. The color red will refer to foods in the ‘preferred foods’ category, color blue will refer to foods in the ‘non-preferred foods’ category, and the color green will refer to foods in ‘new foods’ category. A spinner with nine equal sections of red, blue, and green will be used to move a pawn forward on the game board path. Taking turns, the players will spin the arrow on the spinner and wait for the arrow to land on a designated color. If the arrow lands in the middle it may be spun again. The player then moves their pawn to the designated color square on the path. The selected color square must be the first one on the path; not-like colors are to be skipped over. For example, landing on red on the spinner will require the player to move to the first red square along the path, not skipping over other red squares. All players must follow the encounter rules. Accomplishing an encounter will be rewarded with moving forward 3 spaces. The game is played until the child's pawn reaches the end of the path on the board game, the child's plate is cleared, or the 30-minute session time expires. If the OT or the caregiver reaches the finish line before the child, they may move their pawn to the starting point to help the child complete the game. The purpose of the game is to complete it; however, if a child wins, he or she may be awarded with praise.

Data collection methods. The Dyadic Interaction Nomenclature for Eating (DINE) recordings will supply rich data for researchers to observe and compare before and after the intervention sessions, as well as a comparison between the groups. The DINE will be administered as a pretest and posttest for the experimental and control groups. Two researchers will review pretest and posttest data per participant (Powers et al., 2005; Stark et al., 2000). All behaviors must be coded using the DINE and recordings will be viewed 3 times; viewing # 1 will focus on child behaviors, viewing # 2 will focus on child eating behaviors, and viewing # 3 will concentrate on caregiver behaviors (Piazza-Waggoner et al., 2008; Stark et al., 2000). Behaviors are coded using the DINE based on either demonstration or frequency of the specific behavior within 10-second intervals (Patton et al., 2006). The following seven behaviors are coded based on frequency of behavior within 10-second intervals: the caregivers direct and interrupted commands, the caregiver feeding the child, the child's compliance and noncompliance to direct commands, and the bites and sips taken by the child (see appendix E for coding behaviors chart) (Patton et al., 2006). During intervention sessions, researchers will utilize the encounter checklist (Appendix H). A new, blank, encounter checklist will be filled out during each intervention session. This will allow researchers to compare participants within groups and also compare any changes or progression between the experimental group and the control group as a whole.

 

Feasibility Statement

Timelines of Activities

The finalization of study procedures, activities, and clinical setting space will be completed within the first month followed by approval from the institutional review board (IRB). Participant recruitment will commence shortly after IRB approval. Participants will begin the study as early as the week of their recruitment, and no later than the beginning of Month 5 as shown in Appendix I, the timeline of activities. The study will commence for three consecutive months, allotting time for make-up sessions. Participant’s schedule may be viewed in    Appendix D.

Anticipated Challenges and Solutions

The primary threat to a pretest-posttest study design is attrition (Portney & Watkins, 2009). Due to the requirement of weekly sessions and the length of the study, participants may fail to complete the study. Incentives and flexibility may be viable solutions to encourage active and full participation for the 16-week period.

            With feeding, there is a threat of choking and other emergencies. To ensure the safety of the participants and their caregivers, researchers and occupational therapists (OTs) will be first aid and CPR certified in case of an emergency. To eliminate the threat of foodborne illness, caregivers will be informed to cook all meat thoroughly and rooms will be cleaned after each intervention session.

The presence of food allergies may pose a challenge to this study. Although children with severe food allergies will be excluded from this study, caregivers and OTs may still have food allergies. To account for this, researchers and occupational therapists conducting this study should be made aware of any allergies of persons participating in the study that will be consuming food. EPI-pens will be on site and within close reach during interventions in case of an emergency. OTs providing the interventions must be willing and able to eat the food that the caregiver brings to the intervention session. Therefore, OTs with food allergies or diet restrictions due to personal life choices, health or medical reasons, religious reasons, or cultural reasons will not be used in this study for providing interventions.

Ethical Issues

Families may not be willing or able to bring food for the therapist, due to economical, cultural, or religious reasons. Due to this ethical concern about food (eating, bringing, or sharing) for the intervention, therapists must have a backup source of food for both themselves and for the participants. Food items as a backup for the participants should include typical food, such as fruits, plain rice, cheese, etc. Backup foods for the occupational therapist should also be typical if possible, in order to not arouse unfamiliar scents or intimidate the child with the presentation of other foods. This should be a last resort.

            Due to the personal nature of the materials obtained in this study, all paper documents will be stored in a locked filing cabinet and all recordings will remain password protected and viewed only by the researchers. To maintain anonymity of participants, records will be saved under an assigned number, rather than a name. Also any person appearing in a video recording must sign a consent form, to be submitted with the video recordings. Because video recordings may be beneficial for future research, caregivers will be given the option to release the rights of these recordings to the research team, or have the records sealed following the completion of this research study.

            Caregivers may wish to view the results of their child's progress between the pretest and posttest. Once this study has been completed, caregivers will be given the opportunity to meet with an OT to review both the pretest and the posttest results for their child, as well as the overall results of the study.

 

 

References

 

Archer, L. A., Rosenbaum, P.L, & Streiner, D.L. (1991). The children’s eating behavior inventory: Reliability and validity results. Journal Pediatrics Psychology, 16, 629-642. Retrieved from http://jpepsy.oxfordjournals.org/content/36/5/586.full.pdf+html

Berlin, I. N. (2004). The use of competitive games in play therapy. In C. E. Schaefer & S. E. Reid (Eds.), Game play: Therapeutic use of childhood games (2nd ed., pp. 109-129). Retrieved from https://books.google.com/books?id=3UwHo1boAQkC&lpg=PP1&pg=PP1#v=onepage&q&f=false

Berlin, K. S., & Cerezo, C. S. (2011). Patterns of medical and developmental comorbidities among children presenting with feeding problems: A latent class analysis. Journal of developmental and behavioral pediatrics, 32(1), 41-47.

Christiansen, C. H.; & Baum, C.M. (2005). Occupational therapy: Performance, participation, and well-being. Thorofare, NJ: SLACK Incorporated.

Didehbani, N., Kelly, K., Austin, L., & Wiechmann, A. (2011). Role of parental stress on pediatric feeding disorders. Children’s Health Care, 40, 85-100. doi:10.1080/02739615.2011.564557

Gentry, J. A., & Luiselli, J. K. (2008). Treating a child’s selective eating through parent implemented feeding intervention in the home setting. Journal of Developmental and Physical Disabilities, 20, 63-70. doi:10.1007/s10882-007-9080-6

Gillis, L. (2003). Use of an interactive game to increase food acceptance – a pilot study. Child Care Health Development, 29(5), 373-375. doi:10.1046/j.1365-2214.2003.00354.x

Greer, A. J., Gulotta, C. S., Masler, E. A., & Laud, R. B. (2008). Caregiver stress and outcomes of children with pediatric feeding disorders treated in an intensive interdisciplinary program. Journal of Pediatric Psychology, 33(6), 612-620. doi:10.1093/jpepsy/jsm116

Haidet, K. K., Tate, J., Divirgilio-Thomas, D., Kolanowski, A., & Happ, M. B. (2009). Methods to improve reliability of video- recorded behavioral data. Research in Nursing & Health, 32, 465-474. doi:10.1002/nur.20334           

Matthews, V., Wien, M., & Sabate, J. (2011). The risk of child and adolescent overweight is related to types of food consumed. Nutrition Journal, 10(71). doi:10.1186/1475-2891-10-71

Patel, M., Reed, G. K., Piazza, C. C., Mueller, M., Bachmeyer, M. H., & Layer, S. A. (2007). Use of high-probability instructional sequence to increase compliance to feeding demands in the absence of escape extinction. Behavioral Interventions, 22, 305-310. doi:10.1002/bin.251

Patton, S. R., Dolan, L. M., & Powers, S. W. (2006). Mealtime interactions relate to dietary adherence and glycemic control in young children with type 1 diabetes. Diabetes Care, 29 (5), 1002-1006.            

Piazza-Waggoner, C., Driscoll, K. A., Gilman, D. K., & Powers, S. W. (2008). A comparison using parent report and direct observation in young children with cystic fibrosis: Implications for practical and empirically based behavioral assessment in routine clinical care. Children’s Health Care, 37, 38-48. doi:10.1080/02739610701766875

Portney, L. G. & Watkins, M. P. (2009). Foundations of clinical research: Applications to practice (3rd ed.). Upper Saddle River, NJ: Pearson Education.

Powers, S. W., Mitchell, M. J., Patton, S. R., Byars, K. C,, Jelalian, E., Mulvihill, M., . . . Stark, L. J. (2005). Mealtime behaviors in families of infants and toddlers with cystic fibrosis. Journal of Cystic Fibrosis, 4(3), 175-182.         

Sanders, M., Turner, K., Wall, C., Waugh, L., & Tully, L. (1997). Mealtime behavior and parent – child interaction: A comparison of children with cystic fibrosis, children with feeding problems, and nonclinic controls. Journal of Pediatric Psychology, 22(6), 881-900.     

Schwarz, S. M., Corredor, J., Fisher-Medina, J., Cohen, J., & Robinowitz, S. (2001). Diagnosis and treatment of feeding disorders in children with developmental disabilities. Pediatrics, 108, 671-676.

Stark, L., Jelalian, E., Mulvihill, M., Powers, S., Bowen, A., Spieth, L., . . . Hovell, M. F. (1995). Eating in preschool children with cystic fibrosis and healthy peers: Behavioral analysis. Pediatrics, 95(2), 210-215.

Stark, L., Jelalian, E., Powers, S., Mulvihill, M., Opipari, L., Bowen, A., . . . Hovell, M. F. (2000). Parent and child mealtime behavior in families of children with cystic fibrosis. Journal of Pediatrics, 136(2), 195-200.

Tanta, K. J., & Knox, S. H. (2015). Play. In J. Case-Smith & J. C. O'Brien (Eds.), Occupational therapy for children and adolescents (pp. 483-497). St. Louis, MO: Mosby Elsevier Inc.

Tauer, J. M., & Harackiewicz, J. M. (2004). The effects of cooperation and competition on intrinsic motivation and performance. Journal of Personality and Social Psychology, 86(6), 849-861. doi:10.1037/0022-3514.86.6.849

Thoyre, S. M., Pados, B. F., Park, J., Estrim, H., Hodges, E. A., McComish, C., . . . Murdoch, K. (2014). Development and content validation of the pediatric eating assessment tool (Pedi-EAT). American Journal of Speech-Language Pathology, 23(1), 46-59. doi:10.1044/1058-0360(2013/12-0069)