Family Functioning in School-Age Children With Cystic Fibrosis: An Observational Assessment of Family Interactions in the Mealtime Environment
1 Department of Clinical and Health Psychology, College of Public Health & Health Professions, University of Florida and 2 Division of Psychology, Cincinnati Children’s Hospital Medical Center/University of Cincinnati College of Medicine
All correspondence should be sent to David M. Janicke, PhD, Department of Clinical Health Psychology, University of Florida, PO Box 100165, Gainesville, FL 32610-0165; Lori J. Stark, PhD, Cincinnati Children’s Hospital Medical Center, 3333 Burnet Avenue, Division of Psychology MLC 3015, Cincinnati, OH 45229.
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Objective To examine, using direct observation methodology, differences in family functioning at mealtime between families of school-age children with cystic fibrosis (CF) and families of school-age children without a chronic illness. Method Family functioning was rated using the McMaster Mealtime Interaction Coding System (MICS) during a videotaped dinner among 28 families of children with CF and 27 families of non-ill, age-matched peers. Families were rated on overall family functioning and on six dimensions of the MICS: task accomplishment, communication, affect management, interpersonal involvement, behavior control, and role allocation. Results Ratings for families of a child with CF were significantly lower than they were for comparison families on overall family functioning and on four of the six MICS dimensions: communication, affect management, interpersonal involvement, and behavioral control. Moreover, a significantly greater percentage of families of children with CF were rated in the unhealthy range on overall family functioning and on five of six MICS dimensions. There was no relationship between family functioning and child weight status for children with CF. Conclusions The current study suggests that for families of school-age children with CF, the family system is negatively affected during mealtime. Dietary interventions need to address family-centered, as well as child-centered, interventions to help families manage challenges presented during the family meal.
Key words: cystic fibrosis; family functioning; mealtime; children; behavior.
Nutritional health status in children with cystic fibrosis (CF) is a critical variable related to disease morbidity and mortality (Bell et al., 1998
; Berlinski, Fan, & Oermann, 2002). The primary cause of death is progressive pulmonary disease; however, nutritional status and malnutrition are highly correlated with pulmonary status (Zemel, Jawad, Fitzsimmons, & Stallings, 2000). Despite recent advances in medical management, 17% of patients with CF fall below the fifth percentile of weight for age (Cystic Fibrosis Foundation, 2003). To help children with CF attain normal growth, treatment recommendations include the consumption of 120% to 150% of the recommended daily allowance (RDA) of energy for healthy individuals (Ramsey, Farrell, & Pencharz, 1992).
Getting children to eat and promoting positive nutritional status and growth are challenging tasks for parents, even for families of children without a chronic illness (Kedesdy & Budd, 1998). For families of children with CF, where feeding is a critical illness-management task, eating and feeding become much more complex. Parents must not only prepare the meals and ensure that their children have adequate availability of nutrients but must also encourage their children to consume calories in excess of what is typical for their age and weight (Bowen & Stark, 1991). Eating the type and amount of food necessary to reach the recommended 120% RDA for energy is challenging for children with CF, and observation of mealtime interactions suggests that these children may resist their parents’ efforts to get them to consume more calories (Stark et al., 2000; Stark et al., 2004). Further complicating matters is that the child with CF often has one or more siblings whose nutritional, social, and emotional needs must also be met. As a result of the effort that parents expend to help their children with CF adhere to nutritional recommendations, parents may have less time to tend to the needs of other family members and to engage in the positive interpersonal aspects of the meal (Spieth et al., 2001). Not surprisingly, compromised family functioning at mealtime has been observed in toddlers and preschool-age children with CF (Mitchell, Powers, Dickstein, Byars, & Stark, 2004; Spieth et al., 2001).
Family functioning at mealtime is maximized when interactions promote positive family emotional health and child socialization. In the dinner setting, children are exposed to eating etiquette, manners, and procedures, as well as interaction between family members—all of which convey roles, rules, and values of culture and the family (Feiring & Lewis, 1987). Positive social and family environments encourage eating and facilitate digestion, whereas stressful environments may suppress appetite and discourage food consumption (Stanhope, Wilks, & Hamill, 1994). Thus, interventions are warranted that not only improve dietary adherence but also build cohesive and supportive family environments at mealtime. A critical first step to developing these interventions is to understand if and how family functioning at mealtime is compromised along the developmental continuum.
The school-age years are a critical period for children with CF, presenting unique challenges to families. Despite increased energy intake during these years relative to the preschool years (Stark et al., 1997), school-age children with CF show a gradual but steady decline in average median weight (Cystic Fibrosis Foundation, 2003). Developmentally, school-age children and their parents must cope with the child’s eating more meals away from home, managing energy intake in the context of increased extracurricular activity, adhering to the prescribed regimen of enzyme medications before eating, and expeiencing increased peer pressures (e.g., pressure to be thin; Truby & Paxton, 2001). As families of children with CF cope with the changing context and numerous challenges around eating and meals, parents may feel increased pressure to ensure that their children eat sufficient calories during meals at which they are present.
The purpose of the present study was to expand our understanding of family functioning at mealtime in school-aged children with CF. Whereas most studies of family functioning are based on self-report (Ievers & Drotar, 1996), the current study involved direct observation, which allowed for a rich sample of family interactions in relatively naturalistic conditions. This study assessed not only overall family functioning at mealtime but also other important dimensions of family functioning, including task accomplishment, communication, behavioral control, and affect management. It was hypothesized that school-age children with CF would receive lower—that is, worse—ratings of family functioning than would families of school-age children without a chronic illness. It was also hypothesized that lower weight percentile, lower caloric intake, and lower percent RDA for energy would each be associated with lower overall family functioning.
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Participants
Participant recruitment was described in a previously published manuscript (Stark et al., 1997
) and will be summarized here. In sum, 30 of 64 families who met the eligibility criteria agreed to participate. All families lived within 2 hr of the CF center, spoke English as a primary language, and were not receiving medical treatment that would affect nutritional status—for example, artificial feeding or steroid treatment. Of the 34 families who declined to participate, 19 cited a lack of time, 5 did not wish to be videotaped, 5 stated that they had recently completed a research protocol and wished to take a break, and 5 stated various other reasons. Of the 30 families who agreed to participate in the study, 28 families completed three videotaped dinner sessions. Children ranged in age from 6.0 years to 12.9 years, with a mean of 8.5 years. Children ranged in weight from the 2nd to the 87th percentile. Of the entire sample, 54 percent were male, and all but one of the children were Caucasian. The mean Hollingshead socioeconomic status index was 3.5, which represents a middle- to lower-middle-class background.
Recruited as comparison families to the families of children with CF were 28 families of children without CF matched by age, gender, socioeconomic status, presence of siblings, and number of parents at dinner. Of the 28 families who agreed to participate, 27 completed three videotaped dinner sessions. The children ranged in age from 5.1 years to 12.5 years, with mean age of 8.7 years. The children ranged in weight from the 28th to the 98th percentile. There were no significant differences between the CF group and the comparison group on child age and socioeconomic status (Stark et al., 1997). However, children in the comparison group had a higher average percentile weight for age than did children with CF (68th vs. 26th, respectively), F(1, 54) = 62.20, p < .001. Children from the East Coast recruitment sites (two sites) were also compared to children from the West Coast recruitment site on demographic and health status variables. Across both health status groups (children with CF and children without a chronic illness), families from the West Coast recruitment site had a higher mean Hollingshead index compared to families from the East Coast recruitment sites. There was no difference between East Coast and West Coast sites on child age, weight, weight percentile, RDA per day, calorie intake, and overall mealtime family functioning.
Procedure
Child recruitment.
All families of children with CF within the age range from the three CF centers (one from the West Coast and two from the East Coast) were initially contacted through a letter and then briefed on the study through a follow-up phone call 1 week later. If the family agreed to participate, an initial home visit was scheduled. Comparison families were similarly recruited after being identified through pediatricians, referrals from project staff members, and media announcements. Before recruitment, institutional review board approval was obtained at each of the participating CF centers.
Home visits.
All dependent measures were collected during home visits at dinnertime. Reactivity to the video recording was assessed by parent ratings, comparing the similarity of family interactions during the videotaped dinner to those interactions during routine dinners in the home. Videotaped recordings were scheduled until three dinners rated as "typical" were collected.
At the initial home visit, parents were provided with a Weight Watchers food scale and were taught to keep 3-day diet diaries. Informed consent was obtained at the beginning of the first home visit.
Measures
Mealtime Interaction Coding System (MICS).
The MICS (Dickstein, Hayden, Schiller, Seifer, & San Antonio, 1994; Hayden et al., 1998) was adapted from the McMaster Structured Interview of Family Functioning (MCSIFF) to assess family functioning during an unstructured, naturalistic situation—in this case, family mealtimes. The MICS has been shown to correlate with other measures of family functioning, including the MCSIFF (r = .52), Family Assessment Device (r = .33), Dyadic Adjustment Scale (r = .29–.33), and Parent/Caregiver Involvement Scale (r = .38–.56; Hayden et al., 1998). The dimensions coded within the MICS are similar to those assessed by other McMaster assessment tools, including task accomplishment, communication, affective interaction, interpersonal involvement, behavior control, role allocation, and overall family functioning. It should be noted that overall family functioning is based on specified criteria and is not an average of the other six dimensions. As described by Spieth et al. (2001), each dimension is scored on a 7-point scale ranging from 1 (very unhealthy) to 7 (very healthy). Ratings less than 5 are considered unhealthy and indicate problematic functioning—for example, families are chaotic; there is significant conflict; children and adults have poor behavioral control; assignment of tasks is ineffective; meals may appear forced. Scores of 5 and greater are considered healthy and indicate adequate-to-good functioning—for instance, meals are well-planned and well-managed; basic levels of concern and care are demonstrated; family members do not seem overburdened by the meal; communication is clear and direct. The clinical cutoff for the MICS parallels those established on the MCSIFF and has been validated by data demonstrating the utility of such cutoffs in discriminating families with maternal depression from families with no maternal psychopathology (Dickstein et al., 1998). A complete description of the dimensions of the MICS has been previously reported (Spieth et al., 2001).
Coding and reliability.
Three mealtime interactions rated as typical were collected for data analysis. Previous analysis of similar video-coding procedures of parents’ and children’s behavior during mealtime interactions in families of children with CF revealed no significant differences across the three meals (Stark et al., 1997; Stark et al., 2000). Thus, one videotaped meal was randomly selected and coded for each family. In rating the dimensions of the MICS, coders took notes of observed interactions and evaluated the relevance of those interactions to each of the dimensions. In assigning scores for each dimension, coders first used an overarching set of questions and principles to inform clinical impressions regarding whether a family exhibited qualities of unhealthy (score < 5) or healthy (score 
5) functioning. For example, in understanding how families met challenges related to task accomplishment, coders were guided to determine whether food was prepared and distributed in a safe and organized manner and whether delays, transitions, and disruptions were handled in a way that promoted positive eating. Similarly, communication was rated on the degrees to which members were included and excluded from the communication, to which it was clear and direct, and to the impact of communication patterns on family interactions. In general, families who received ratings in the unhealthy range might be characterized by inconsistent behavior management strategies, parental disagreements about discipline, indirect and masked communication, highly charged or flat affective responsiveness, or inefficient role allocation. In contrast, families in the healthy range showed adequate-to-excellent functioning, as they were able to manage behavior and affect, display a range of appropriate affect, communicate effectively with all family members, and coordinate the meals. Thus, observations of family interactions were scored using a detailed scoring guide that outlined criteria for rating families across seven domains using a 7-point Likert scale. Ratings were assigned along this continuum based on the family’s interactions relative to scoring criteria and to the theoretical premise of the McMaster model that scores of 5 and above are in the healthy range and scores below 5 are in the unhealthy range. Coding of interactions began when food was placed on the table and when at least one family member initiated eating. Coding was terminated at the end of the meal or after 20 min, whichever occurred first.
Coders were trained to reliability of .80 or greater on the MICS by coding 30 archival videotapes of family meals, all previously coded. In the current study, 25% of the meals were coded for reliability by a second rater trained on the MICS. The primary and reliability coders were unaware of participants’ health status. Reliability was assessed using intraclass correlations. Intraclass correlations are appropriate for Likert ratings and evaluate exact agreement of ratings, thus avoiding potentially inflated correlation coefficients resulting from consistent disagreements between two raters (Winer, Brown, & Michels, 1991). In the current study, intraclass correlations were above .60 for each of the MICS dimensions: .73 task accomplishment; .79 communication; .76 affective involvement; .93 interpersonal involvement; .64 behavior control; .86 role allocation; and .82 overall family functioning.
Coder awareness of the participants’ health status was broken within seven families when the coder observed the child taking their pancreatic enzymes (pills) during the videotaped meal. To assess for potential rater bias, the ratings of these seven families were compared to the ratings of other families of children with CF where the coder remained unaware of the participants’ health status. Although the ratings on all dimensions of family functioning were slightly better for families in which the blind was broken relative to those families in which the blind was not broken (in the opposite direction of the study hypothesis), there was no significant difference between these two groups (t values ranged from .22 to 1.089; all p > .05).
Data Analysis
A multiple analysis of variance was first conducted to assess for any difference in level of mealtime family functioning between families of children with CF and comparison families. Subsequent univariate analyses of overall family functioning and individual MICS subscales were conducted using a one-way analysis of variance. Pearson product-moment correlations were conducted to evaluate the relationships between overall family functioning and child’s weight status, caloric intake, and percentage RDA for energy in the families with a child with CF only.
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Figure 1 displays the average ratings on each of the MICS dimensions for families of a child with CF and for comparison families. The multiple analysis of variance revealed a significant difference between the CF groups and the comparison groups, F(7, 41) = 3.291, p = .006. As seen in Figure 1, families of a child with CF had lower (worse) ratings than did families of a comparison child. Follow-up univariate analyses revealed that families of a child with CF scored lower than did non-CF families on ratings of overall family functioning, F(1, 54) = 12.638, p < .01; communication, F(1, 54) = 13.857, p < .001; affect management, F(1, 54) = 15.351, p < .001; interpersonal involvement, F(1, 54) = 15.959, p < .001; and behavioral control F(1, 54) = 12.068, p = .001. There was no difference between the CF and the comparison group on the dimensions of task accomplishment, F(1, 54) = 2.515, p > .05, and role allocation, F(1, 54) = 2.311, p > .05.
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Figure 2 displays the percentage of families scoring in the unhealthy range on each of the MICS dimensions. Chi-square analyses revealed a significant difference between the percentage of families of a child with CF and the percentage of comparison families rated in the unhealthy range on overall family functioning (
2 = 6.76; p < .01), task accomplishment (2 = 4.14; p < .05), communication (2 = 5.34; p < .05), affective management (2 = 8.05; p < .01), interpersonal involvement (2 = 8.04; p < .05), and behavioral control (2 = 7.30; p < .01). There was no difference between CF and comparison families in the percentage of families in the unhealthy range on role allocation (2 = 0.77; p > .05).
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Correlational analyses were also conducted to examine the relationship between overall family functioning and three nutritional status variables for the CF sample. Pearson’s product-moment correlations revealed no significant association between overall family functioning and weight percentile for age (r = .278), caloric intake (r = .046), and percentage RDA per day (r = .116).
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Discussion |
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This study extends our understanding of mealtime interactions in families of children with CF by going beyond parent–child dyadic interactions to assessing how the family system may be affected at mealtime by dietary treatment of CF in school-age children. In the current sample, families of school-age children with CF exhibited a range of functioning and interaction patterns during mealtime. Whereas a number of families of children with CF exhibited growth-promoting, supportive, and effective patterns of family interactions, a large number of families of children with CF demonstrated less-than-optimal patterns of family interactions. On average, family functioning at mealtime was lower for families of school-age children with CF relative to families of comparison children without a chronic illness on overall family functioning and on four of six dimensions of the MICS. When examined alongside previous studies of mealtime family functioning in toddlers (Mitchell et al., 2004
) and in preschool children with CF (Spieth et al., 2001), these results suggest that across the developmental continuum many families of children with CF exhibit problematic interaction patterns and family functioning at mealtime.
Given that the MICS assessed multiple dimensions of family functioning, it is important to note two exceptions to the findings of greater problematic family functioning at mealtime in the school-age population of children with CF. Contrary to data from toddler and preschool-age populations, ratings of role allocation did not differ between families of children with CF and comparison families. It may be that when children reach school-age, they are able to engage in the type of age-appropriate tasks that can reduce some of the parental burden. For example, school-age children are better equipped to independently pour milk, set the table, serve food, and cut their food. Whereas parents may still be challenged by the need to get their child with CF to consume more calories, the child’s ability to help with other meal-related tasks may reduce some of the parental demands. The finding that task accomplishment was not significantly different in families of school-age children with CF relative to comparison families is similar to findings based on toddler and preschool-age children with CF (Mitchell et al., 2004; Spieth et al., 2001).
When functioning on these two domains—role allocation and task accomplishment—is examined in light of the problematic functioning on other MICS dimensions, one suggestion revealed is that while families of children with CF are successful at getting dinner on the table and ensuring that the meal proceeds smoothly, many families are struggling to meet the multiple demands presented during mealtime. Although no definitive conclusions can be drawn about the causality of these less-than-optimal family interaction patterns, it is likely that for many families the efforts required by parents to manage the child’s dietary regimen may limit their ability to attend to emotional and interactional aspects of the meal. Parents may also alter family rules or interaction patterns to get their child with CF to meet their dietary goals. For example, parents may implement more-rigid standards for dietary compliance and mealtime behavior to help their child increase caloric intake. Although focusing on the task-oriented and mechanical strategies of the meal may be effective in the short term by ensuring that children eat as recommended, they may be prioritized over creating a nurturing, interactive, and emotionally supportive style within the mealtime family environment.
Although the means for overall family functioning and for four of six MICS dimensions show statistically significant differences between CF and control groups, the clinical significance of these differences is less certain. The clinical significance of the MICS has not been fully established; however, clinical utility of the MICS has shown promise in distinguishing between clinically relevant dimensions indicative of healthy and unhealthy functioning (Dickstein, et al., 1998). In the current sample, problematic interaction patterns were manifested in a number of ways, including coercive or masked communication, negative affect or emotional lability, inconsistent use of behavior management strategies, rigid behavioral standards, lack of quality exchanges about the day’s events, and lack of developmentally appropriate affection and support. These types of interactions may have negative implications for families. However, classifying families as unhealthy may not be appropriate given the context in which CF families are making decisions related to adherence, physical health, and survival. In fact, it may be that task-focused, rather than emotionally focused, approaches to the mealtime may be adaptive, particularly given that role allocation was not compromised in the CF group relative to the control sample.
In the current study, the child’s weight status was not related to family functioning. Although there was also no relationship found between child’s weight status and family functioning in preschool-aged children with CF, the lack of a relationship is particularly striking in this sample. Preschool-aged children with CF are typically doing well, as epidemiological data indicate that the peak of average weight status for age is attained at age 4 (Cystic Fibrosis Foundation, 2003). However, in school-age children with CF, the average weight percentile shows a gradual decline. Thus, it was expected that parents would feel increased pressure around meals as their children fell further behind their non-ill peers in weight status and that this would subsequently be manifested as increased family stress at mealtime for those children with CF who were at lower weight percentiles. This was not the case. One possible explanation for this finding is that other variables—such as pulmonary functioning, adherence to medical enzymes, or an ineffective treatment plan—may negatively affect the child’s weight status, independent of eating or mealtime behaviors.
One limitation of the current study is the recruitment rate. Although there was no difference on height and weight status between those who participated and those who declined, participants may have differed in other ways that could have affected the generalizability of these findings. It is also important to note that variations in health status may have important implications on dietary intake and the family mealtime environment. Unfortunately, we did not have information pertaining to the disease status of the children with CF and thus were unable to determine if disease severity affected the family mealtime environment in this sample. Furthermore, although the interrater reliability for most of the MICS dimensions were quite good, the interrater reliability for behavioral control, although acceptable (.64), was lower than other dimensions. This is consistent with a study by Spieth and colleagues (Spieth et al., 2001) that found the interrater reliability for behavior control to be the lowest (.67) of the MICS dimensions in a sample of preschool-aged children with CF. One possible explanation for the lower reliability on this dimension is that the scale rates the way in which the family expresses and maintains standards for the behavior of its members, with ratings organized within a framework of four parenting/behavioral styles (chaotic, laissez-faire, rigid, and flexible). These ratings may be difficult to assign relative to other MICS dimensions, as parenting styles may vary throughout the meal.
Behavioral intervention has been successful in reducing negative parent–child interactions and in improving caloric intake in children with CF (Stark, Powers, Jelalian, Rape, & Miller, 1994). However, the impact of behavioral intervention on the family system at mealtime has not been assessed. It may be that the quality of family interactions improves as parents learn more-effective strategies for getting children to increase their energy intake. Future research should assess this possibility. If it is found that behavioral interventions do not improve family functioning, we will need to determine how to modify these interventions to address family interactions as well as how to optimize caloric intake in children with CF. The dimensions of the MICS can provide key information in designing a family-focused component in behavioral treatment. Moreover, data suggests less than optimal family functioning at mealtime along the developmental continuum in families of children with CF, it will also be beneficial to determine the optimal time to intervene with families to improve caloric intake and family functioning. Early intervention during the toddler or preschool years may improve nutrition and health, which may also enhance family interactions over time. Clinical nutritional management is an integral and challenging aspect of the treatment regimen for a number of pediatric chronic conditions (Mackner, McGrath, & Stark, 2001). As such, future research should examine whether these suboptimal patterns of mealtime family functioning found in families of children with CF are found in other pediatric chronic conditions where dietary treatment is critical to the child’s health status.
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The research was supported by grant Z-117 from the National Cystic Fibrosis Foundation and by grant K24 DK59492 from the National Institutes of Health to Lori J. Stark, PhD.
Received November 11, 2003; revision received March 20, 2004; revision received May 28, 2004; accepted June 7, 2004
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