Research Brief
‘‘Are you done?’’ Child Care Providers’ Verbal
Communication at Mealtimes That Reinforce or Hinder
Children’s Internal Cues of Hunger and Satiation
Samantha A. Ramsay, MS, RD, LD1; Laurel J. Branen, PhD, RD, LD1; Janice Fletcher, EdD1;
Elizabeth Price, PhD2; Susan L. Johnson, PhD3; Madeleine Sigman-Grant, PhD, RD4
ABSTRACT
Objective: To explore the verbal communication of child care providers regarding preschool children’s
internal and non-internal hunger and satiation cues.
Methods: Video observation transcripts of Head Start staff (n ¼ 29) at licensed child care centers in
Colorado, Idaho, and Nevada were analyzed for common themes.
Results: Adults’ verbal communication with children at mealtimes emphasized non-internal cues: (1)
cueing children to amounts without referencing children’s internal cues; (2) meal termination time; (3) asking children if they wanted more without referencing their internal cues; (4) asking children if they were
done without referencing their internal cues; (5) telling children to take, try, eat, or finish food; (6) praising
children for eating; and (7) telling children about food being good for you. Adults demonstrated an
overriding effort to get children to eat.
Conclusions and Implications: Training needs to be developed that gives specifics on verbally cueing
young children to their internal hunger and satiation cues.
Key Words: child, child care, mealtimes, hunger and satiation, internal cues (J Nutr Educ Behav.
2010;42:265-270.)
INTRODUCTION
The rising prevalence of childhood
obesity has triggered interest in explaining contributing factors.1 Fisher
and Birch note a behavioral factor of
eating in the absence of hunger.2 Children are born with the capacity to recognize hunger and satiation, and more
importantly, to self-regulate their intake of food,3,4 and this capacity to
self-regulate food intake continues
throughout early childhood.5-7 This
capacity is fostered when adults follow
Satter’s division of responsibility in
adult and child roles, where children
choose how much food they want to
eat from the food adults offer.8 However, the division of responsibility is
not always followed, and too often,
children’s cues are overridden by
what adults say to them.
Verbally cueing children to attend
to hunger and satiation can be supportive of their self-regulation of energy intake, however there is
evidence demonstrating that adults’
verbal communication at mealtimes
is predominantly detrimental to children’s attention to internal cues of
1
Department of Family and Consumer Sciences, University of Idaho, Coeur d’Alene, ID
Department of Family and Consumer Sciences, University of Idaho, Moscow, ID
3
Department of Pediatrics, University of Colorado Denver, CO
4
University of Nevada Cooperative Extension Southern Area, Reno, NV
The fifth author of this article (Johnson) serves on the JNEB staff as an Associate Editor. Review of this article was handled, exclusively, by another Associate Editor (Murimi) to minimize conflict of interest.
Address for correspondence: Samantha A. Ramsay, MS, RD, LD, University of Idaho,
Coeur d’Alene, 1000 W. Hubbard Ave, Suite 145, Coeur d’Alene, ID 83814; Phone:
(208) 292-2541; Fax: (208) 664-1272; E-mail: [email protected]
PUBLISHED BY ELSEVIER INC. ON BEHALF OF THE SOCIETY FOR NUTRITION EDUCATION
doi:10.1016/j.jneb.2009.07.002
2
Journal of Nutrition Education and Behavior Volume 42, Number 4, 2010
hunger and fullness.9-11 Adults often
override young children’s internal
cues of hunger and satiation by controlling food intake, rewarding and
bribing with food, and restricting
food.6,12-14 In a seminal study, Birch
et al examined the impact of internal
and external cues on children’s food
intake.6 Children who were cued to
the amount of food on their plate
and given rewards for eating showed
less responsiveness to hunger and satiation as compared to children who
were cued to their hunger and satiation while eating. Fletcher et al also
reported that older adolescents’ perceptions of their caregivers’ feeding behaviors during early childhood disrupted
their internal cues, namely, being required to clean their plates, being given
food incentives to get them to do
things, and caregivers determining
how much they were to eat.13
These behaviors that override children’s internal cues are not restricted
to feeding practices occurring in the
home environment. Child care providers have also been reported to use
directive feeding practices, such as
controlling children’s food and portions, asserting the sequence in which
265
266 Ramsay et al
food may be eaten, and having attitudes and beliefs that can encourage
children to overeat.14 Some controlling feeding practices, such as efforts
to get children to eat more, stem
from their concerns about making
sure children get enough food, since
they may be experiencing food insecurity at home.15
The above studies demonstrate
that internal cues are often overridden by the type of adult verbal communication used at mealtimes, both
at home and in child care settings.
An analysis of family meals in the
home with 5-year-old children identified a number of parental verbal
strategies, for example, neutral
prompts, pressure/demand to eat,
reasoning, food reward, praise, food
restriction and portion control,
threat to withhold food, threat to
withhold play, and offering play as
a reward for eating.10 Examples of
statements included: ‘‘If you eat 3
more bites of meat, you can have
a Popsicle’’ and ‘‘if you don’t finish
your peas, no brownie.’’ 10 The overall parental theme identified was verbal communication that emphasized
a need to get children to eat more
during meals. Phrases also were
made regardless of children’s internal cues of hunger and satiation,
such as, ‘‘When I say eat, you eat.’’10
The studies reported above shed
light on how verbal communication
in the home environment does not
emphasize children’s internal cues of
hunger and satiation. However, the
use of verbal cues influencing children’s eating in child care settings
has not been examined. With over 20
million children in child care,16 characterizing verbal communications
occurring at mealtimes in child care
settings could reveal important influences on the development of children’s eating styles and could identify
opportunities for intervention.
With the goal of gaining more understanding of verbal communication
related to children’s internal cues of
hunger and satiation in the child
care setting, the present study’s research objective was to characterize
child care providers’ verbal communications related to children’s food intake and to compare the frequency
of their use of non-internal verbal
communication to internal verbal
communication.
Journal of Nutrition Education and Behavior Volume 42, Number 4, 2010
METHODS
Recruitment
A convenience sample of accredited/
licensed child care centers meeting
specific criteria of geographic and demographic diversity were purposefully selected to participate in 26
video observations of mealtimes serving children 14 months to 67 months
of age as part of a larger study.17 The
centers were located in Colorado,
Idaho, and Nevada and included urban and rural sites. Internal review
boards from the University of Idaho;
the University of Colorado Denver;
and the University of Nevada, Reno
approved the study. Consent was secured from the center director and
classroom staff involved in each video
observation. Parental consent was obtained for the children in the classroom who would be videotaped.
Children assented to be taped, and if
a child did not want to be taped, he
or she was not required to participate
and was placed in another room. The
parent of 1 child refused to give consent.
Video Data Collection
Two videographers recorded each observation. Videographers were trained
using a video observation protocol to
ensure consistency in data collection.18 Additional information about
the mealtime, including room arrangement and equipment, menu,
staff presence at the mealtime, and
mealtime procedures, were noted on
a video observation sheet that accompanied the video recording.
Two cameras focused on the
teacher and children at 1 table during
mealtime for each video observation.
Cameras were placed to provide complete coverage of the table. Camera I
was positioned to record the teacher
and children adjacent to the teacher.
Camera II was positioned to record
children at the table not visible to
Camera I. A pressure zone microphone (PZM) and directional microphones were used to enhance the
audiorecording and to overcome extraneous room noise.
Procedures
All vocalizations from the video observations were transcribed, and actions
were explained in writing. Videorecordings from both cameras were
viewed and transcribed using a 2-column protocol, 1 column for each
camera. This procedure allowed for
mealtime conversations and events
to be reviewed intact.
The authors examined 2 categories
to differentiate adults’ comments to
children about eating: those that cue
the child to internal awareness of
hunger and satiation, and those that
do not. Parham and Nelson defined
internal cues as ‘‘physiological or internal stimuli.’’19 Building on this
definition, the authors in this study
defined internal comments as any
adult verbalization in reference to
a child’s internal feeling of hunger
and satiation, for example, ‘‘Does
your tummy feel full?’’ Those comments that do not reference children’s internal cues are categorized
as non-internal comments, which included comments about the amount
of food eaten or the child’s intake of
food without explicitly referencing
the child’s feeling of hunger and satiation, for example, ‘‘Finish your sandwich.’’
Using the definitions of internal
comments and non-internal comments, the transcripts were analyzed
in 2-minute segments. Content analysis of the transcripts followed the
guidelines of Weber to reduce the
text to the category themes, identify
words or phrases, and assign them to
one of those categories.20
Reliability and Validity
To establish interpretability and reliability, all transcripts were independently analyzed by 2 trained
researchers using the procedures of
Carmines and Zeller.21 Scoring revealed a reliability k coefficient of
0.80. Validity was addressed in several ways. First, the categories to determine cues for internal versus
non-internal words and phrases
were defined based on previous research.19 Second, the definitions
were further reviewed by child feeding experts to establish face and content validity prior to content
analysis. Finally, threats to external
validity were minimized by using
video observation data from multiple
sites in 3 states.
Journal of Nutrition Education and Behavior Volume 42, Number 4, 2010
RESULTS
Classroom Characteristics
In 26 child care centers in Colorado,
Idaho, and Nevada, a total of 29 adults
and 127 children participated in the
mealtime observations (Table 1). Children ranged in age from 14 months to
67 months. On average, 11 children
were served per classroom, with
a range of 3 to 23, and on average 5
children were seated at the table,
with a range of 2 to 7 children.
Twenty-three child care centers had
a teacher at the table, 2 centers had
both a teacher and an assistant
teacher, and 1 center had a teacher
and a senior volunteer.
Comments Made to Children at
Mealtimes
A variety of comments were made to
children at mealtimes with reference
to their eating (Table 2). Four themes
emerged related to internal comments: (1) references to a child being
hungry or thirsty; (2) references to
the child liking a food because it
makes their tummy feel good; (3) letting the child know they could have
more if they were still hungry; and
(4) references to the child being full.
Seven themes emerged from the comments adults made that were noninternal: (1) cueing children to
amounts without letting the child
know they could have more food if
he or she was still hungry; (2) time
for meal termination; (3) asking
a child if he or she wanted more, without a reference to the child’s hunger
and satiation; (4) asking the child if
he or she was done, without a reference to their hunger and satiation;
(5) telling a child to take food, try
food, eat food, or finish food; (6) praising the child for eating; and (7) telling
the child information about food being good or good for him or her to
get the child to eat. In total, 418 comments were made, with 10 times more
non-internal comments than internal
comments (Table 2).
Mealtime Phases
Three distinct mealtime phases became apparent in terms of the type
of comments adults made to children
at mealtimes in child care settings.
Table 1. Demographics of the
Classrooms Participating in Mealtime
Observations and the Type of Meal
Offered (n ¼ 26)
Number of
classrooms
(%)
Demographics
Sites
Colorado
8 (31)
Idaho
10 (38)
Nevada
8 (31)
Type of service observed
Pre-plated
2 (8)
Pre-plates first serving
1 (4)
Self-service
21 (80)
Lunch box
2 (8)
Accredited
21 (80)
State licensed
26 (100)
CACFP
20 (77)
Type of meal
Lunch
24
Breakfast
2
CACFP indicates Child and Adult
Care Food Program.
The types of comments were differentiated to an initial phase, a middle
phase, or a final phase.
Initial
phase. During the initial
phase, adults’ comments were primarily centered on non-internal comments directing the child to get the
right amount or suggesting the child
was taking too much food. Adult comments such as ‘‘Grab one [sandwich]’’
or ‘‘That’s enough’’ were made. These
comments were made primarily to facilitate the mealtime, ensure all children had the opportunity to access
available food, and to encourage children to put food on their plates at the
beginning of the meal. Examples of
the internal comments during the initial phase included ‘‘Are you hungry?’’
or ‘‘You’re thirsty?’’
Middle phase. The middle or keep
eating phase of the meal included verbal comments that were intended to
help the children stay focused on eating. Four types of comments were
identified during this phase: (1) telling the child to take food, try food,
eat food, or finish food; (2) praising
the child for eating: (3) telling the
Ramsay et al 267
child information about how the
food is good for him or her: and (4)
comments asking the child if he or
she wanted more, without any reference to the child’s hunger or satiation.
The first type of comment was
aimed toward getting children to eat.
Adults would tell children to put
food on their plates or to eat or drink
‘‘even just a little bit.’’ Children were
told they had to eat a particular food
before they were allowed to have
more of another food they preferred.
Comments were made regarding children not being allowed to have dessert
first or the child needed to make
a ‘‘happy plate,’’ meaning cleaning
the plate. Adults also used statements
such as ‘‘Can you put a tiny bit on
your plate? Just try it,’’ or ‘‘I think
you need some milk.’’
The second type of comment
adults made was offering praise for
eating. Reinforcing comments were
made about children being good or
special for eating certain food items.
Comments such as ‘‘Be a good eater,’’
and ‘‘I’m glad your sister eats a lot’’
were made. There were also adult
comments praising children for eating
all of a specific food or cleaning their
plates.
The third type of comment consisted of offering information about
food tasting good or being healthful.
Comments were made to cue the
child to eat or drink a particular food
because it is good for them. For example, comments were made such as
‘‘Milk will make your teeth strong
and healthy,’’ ‘‘Salad will make you
grow,’’ and ‘‘He ate all the kiwi, so he
got some big muscles.’’
In the fourth type of comment,
adults were asking a child if he or she
wanted more food or beverage, without reference to whether the child
was still hungry or getting full. For example, after a child poured a little milk
in a cup, the adult commented, ‘‘That’s
it? You want some more?’’
Non-internal comments dominated the middle phase. Only a small
number, 21 out of 224 comments
(9%), supported children’s internal
cues. The internal comments that
were made asked the children if the
food made their tummies feel good or
reassured children that they could
have more food if they were still hungry. An example of a comment that
supports internal cues made during
268 Ramsay et al
Journal of Nutrition Education and Behavior Volume 42, Number 4, 2010
Table 2. Number and Type of Comments Adults Made to Children Related to
Children’s Internal Cues of Hunger and Satiation
Comment to the Child
Number of Comments Made (%)
Non-internal themes
Cue children to amounts
22 (5.8)
‘‘Take 2 scoops, okay.’’
Time for meal termination
8 (2.1)
‘‘Let’s go, hurry up, it’s time to go.’’
‘‘Lunch time is over.’’
Asking child if he or she wants more without
80 (21.1)
referencing hunger
‘‘You want some more?’’
Asking whether or telling child he or she is done
126 (33.2)
‘‘Are you done?’’
‘‘When you’re playing with your cup, you’re
showing me you’re done.’’
Telling child to take food, try food, eat food, or
125 (32.9)
finish food
‘‘Drink some milk at least, huh, even if it’s just
a little bit.’’
‘‘Can you put a little tiny bit on your plate?
Just try it?’’
‘‘Let’s see you make a happy plate.’’ [clean
plate]
Praising child
10 (2.6)
‘‘You are the vegetable queen, the vegetable
lady.’’
‘‘We are good eaters, [child’s name] and I. I
like the way she eats; she eats all her
[food].’’
Information about food being good or good for
7 (1.8)
you.
‘‘Mmm. Mmm. It’s good, eat some.’’
‘‘Milk will make you big and strong like
mommy.’’
Total: 380
Internal themes
Referencing hunger or thirst
22 (58)
‘‘Were you hungry?’’
Referencing to liking the food because it makes
3 (8)
child’s tummy feel good
‘‘Does it make your tummy happy?’’
Letting the child know he or she can have more,
9 (24)
referencing hunger
‘‘When we run out of those, if you’re still
hungry; you’ll have to try some green
beans or some fruit.’’
Reference to the child being full
4 (11)
‘‘Are you full?’’
Total: 38
the middle phase was ‘‘You are hungry
today.’’
Final phase. The third phase was the
period of time when the meal was
coming to completion. Most of the
adults’ comments made to children
were attempts to finalize the meal,
such as asking the child if he or she
was done or finished. The questions
were often asked repeatedly, even
when children continued to serve
themselves more food or were still eating. These comments were not followed by any reference to the child’s
internal state. Only 4 internal comments out of 126 (3%) involved asking the child if he or she was full or
if his or her tummy was full.
DISCUSSION
This study aimed to provide a description and gain insights into adults’
communication at mealtimes in child
care settings related to children’s internal cues of hunger and satiation.
When caregivers incorporate strategies such as comments cueing children to their hunger and fullness,
they support children’s sensitivity to
energy density in their diet and reinforce their self-regulation skills.9 Supporting children’s self-regulation of
intake by adopting appropriate feeding practices is part of the American
Dietetic Association’s benchmarks for
child care settings.22 Feeding practices
related to vocalizations that do not
support children’s internal cues have
been previously identified,10-14 however, little research has examined the
types of comments made to children
at mealtimes in child care. The present findings suggest that the majority
of comments made to children in
child care were non-internal. ‘‘Are
you done?’’ was a commonly used
phrase at mealtimes and accounted
for 126 comments out of the total
418 (30%). Child care providers may
be using this phrase with the intention of cueing children to their fullness when in actuality this phrase
does not reference their internal cues
of hunger and satiation. In addition,
the comments directed at getting children to eat, such as ‘‘Can you eat for
me?’’ were made without evaluating
a child’s hunger or satiation and could
override the child’s internal cues.
Adults’ verbal communication that
emphasized the need for children to
eat is consistent with previous research of adults’ communication
with
children
during
family
meals.10,11,15,23
In the present study, comments
made to children at mealtimes seem
to follow 3 distinct phases: the initial
phase of cueing children to enough
food or to take food; a middle phase
Journal of Nutrition Education and Behavior Volume 42, Number 4, 2010
of keeping the child focused on eating
or to keep eating; and a final phase of
finishing the meal. Phases during
mealtimes that have been noted examined specific food comments and
food pragmatics, such as asking for
and passing the food, over the course
of the mealtime (C. Ellefson, unpublished data, 2005). Our study supports
the concept of mealtime phases related to caregivers’ internal and noninternal comments to children at
mealtimes in child care centers. Recognizing that children are learning different skills at different phases during
the meal is informative for selecting
process-focused verbal reinforcement
strategies appropriate to help children
be self-regulating eaters.24
Limitations of the Research
The study sample consisted of a convenience sample of 26 child care centers,
and the qualitative nature of the data
does not allow the data to be generalized to the entire population of child
care settings. In addition, the verbal
interactions between the adult and
child at mealtimes could be influenced by the presence of the video
camera and videographer, which are
required for recording the mealtimes.
Although the presence of technological equipment invariably influences
an individual’s behaviors, trained videographers followed strict protocol to
minimize their presence while videorecording. Previous research demonstrated that camera comments
accounted for 1% of overall mealtime
talk, suggesting that taping does not
necessarily affect the mealtimes observed (C. Ellefson, unpublished
data, 2005).
ing their comments to each of the 3
phases of mealtimes. Results from
this study suggest training for child
care settings is needed to enhance
child care providers’ verbal comments
to children at mealtimes.
Further research should focus on
understanding adults’ and children’s
interpretations of non-internal comments and whether they help or hinder children’s recognition of internal
cues. For example, when adults ask
children whether they ‘‘are done,’’ is
their intention to support children’s
ability to recognize fullness, or are
there other factors influencing mealtime completion, such as time? Being
intentional with language during
mealtime conversations seems to be
important and should be further investigated as a method to enhance children’s self-regulation skills. For
example, are phrases such as ‘‘Are you
full?’’ more effective in helping to reinforce children’s internal cues of hunger
and satiation than other non-internal
verbal communication? In addition,
further research should study child
care providers’ tone and intonation
with the use of specific phrases and
how it may also influence children’s
recognition of internal cues.
There is also a benefit in understanding adults’ perceptions of mealtimes and how those perceptions
influence their vocalizations and practices, both in family mealtimes and
child care settings. The identification
of 3 mealtime phases sheds light on
factors that influence mealtime vocalizations such as time, food availability,
schedules, other children at the table,
and the ratio of adults to children at
mealtimes. Further research should investigate the mechanisms by which
these constraints influence mealtime
phases and adult vocalizations.
IMPLICATIONS FOR
RESEARCH AND
PRACTICE
ACKNOWLEDGMENTS
Findings from this study suggest that
child care providers need to be educated on appropriate verbalizations
that support hunger and satiation.
Satter has provided an excellent foundation with her division of responsibility.8 Building on this scheme,
adults can reinforce children’s selfregulation through vocalization at
mealtimes. Adults can further support
the internal cues of children by tailor-
This project was supported by the Initiative for Future Agriculture and Food
Systems Grant no. 2001-52102-11202
from the US Department of Agriculture Cooperative State Research, Education, and Extension Service. The
research team thanks Sarah Collyer
Matthews for her videographer and
transcription work and Kristin Hansen for her assistance in testing the reliability
Ramsay et al 269
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