Development and Content Validation of the Child Oral and Motor Proficiency Scale (ChOMPS)

Abstract

This article describes the development and content validation of the Child Oral and Motor Proficiency Scale (ChOMPS), a parent-report assessment of eating, drinking, and related skills in children 6 months to 7 years of age. Initially, 69 items for the ChOMPS were generated from literature review. Nineteen professionals evaluated the ChOMPS using content validity indices (CVI). Significant revisions were made to items and directions based on professional feedback. CVI were acceptable for both the relevance and clarity of items. Cognitive interviews were then conducted with 19 parents to explore parent understanding of items. Additional revisions were made based on parent feedback. The reading grade level of the resulting ChOMPS was less than sixth grade. The 70-item ChOMPS has evidence of content validity, indicating the items are relevant and clear to professionals, and parents understand the directions and items as intended.

Keywords

assessment children development infants screening

Introduction

Problematic feeding occurs when a child is unable or unwilling to safely eat and/or drink enough volume or variety by mouth, despite availability of adequate food, to obtain the nutrition and hydration necessary for appropriate growth and development (Estrem, Pados, Park, Knafl, & Thoyre, 2016; Kedesdy & Budd, 1998). Although epidemiologic studies of this phenomenon have not been conducted, it is estimated that 25% of typically developing children and up to 80% of children with developmental disabilities experience difficulty with feeding (Field, Garland, & Williams, 2003; Manikam & Perman, 2000). With the increasing survival of critically ill infants and young children, there is a growing population of children with complex medical problems who are at risk for feeding problems (Boyle et al., 2011; Burns et al., 2010; Stoll et al., 2015).

Pediatric feeding problems are heterogeneous in nature, with presentations ranging from “picky eating” to complete reliance on nonoral means for nutrition and hydration. Feeding problems also cut across diagnostic categories and affect a wide variety of infants and children, including, but not limited to, infants born prematurely and with congenital heart disease, genetic conditions, birth defects, cerebral palsy, autism spectrum disorder, pediatric cancer, food allergies, and type 1 diabetes, and some typically developing children with no known medical conditions (Benfer et al., 2013; Clemente, Barnes, Shinebourne, & Stein, 2001; Cooper-Brown et al., 2008; Dellon, Jensen, Martin, Shaheen, & Kappelman, 2014; Green, Horn, & Erickson, 2010; Johnson et al., 2016; Miller, 2011; Patton, Dolan, & Powers, 2006; Williams, Gibbons, & Schreck, 2005). Feeding difficulties early in life can result in micro- and macronutrient deficiencies during a time of critical brain development (Malhi, Venkatesh, Bharti, & Singhi, 2017; Northstone & Emmett, 2013). Adequate nutrition during the first 2 years of life is essential for optimal neurodevelopment (Georgieff, Brunette, & Tran, 2015). Feeding problems have high clinical significance, but the heterogeneous nature of the problem often makes diagnosis difficult, resulting in delayed identification and initiation of feeding therapy. Delayed identification can have long-term implications for the child’s feeding. Late introduction to solid foods (after 9 months of age), which may be an indication of delayed eating skill, is associated with selective intake of fruits and vegetables and significantly more feeding problems at 7 years of age (Coulthard, Harris, & Emmett, 2009). Although skills that are typically learned during the first 2 years can be learned later, more specialized training techniques and longer periods of time may be required for an older child to acquire the same skill (Piek, 2006; Sheppard, 2008).

Although pediatric feeding problems are common and increasing in frequency, there is a lack of valid and reliable assessment tools available to health care providers to facilitate identification of infants and young children in need of specialty feeding assessment and treatment and to assess effectiveness of therapeutic strategies (Barton, Bickell, & Fucile, 2018; Pados, Park, Estrem, & Awotwi, 2016; Speyer, Cordier, Parsons, Denman, & Kim, 2018). Two recent systematic reviews have evaluated the currently available noninstrumental pediatric oral motor and swallowing feeding assessment tools, and both reviews determined that none of the tools have evidence of adequate psychometric properties (Barton et al., 2018; Speyer et al., 2018). In addition, none of the currently available assessment tools comprehensively assesses a child’s gross, fine, and oral motor skills that support safe, age-appropriate eating.

Our research team developed the Pediatric Eating Assessment Tool (PediEAT) to measure behavioral symptoms of problematic feeding in young children (Pados, Thoyre, & Park, 2018b; Thoyre et al., 2018; Thoyre et al., 2014). In the PediEAT, we intentionally separated feeding behaviors from eating skills. Although feeding behaviors and eating skills are highly interrelated, instrument development guidelines direct investigators to avoid mixing constructs (DeVellis, 2012). Feeding behaviors and eating skills are clearly different constructs of feeding. What a child is willing to eat (feeding behavior) and what a child can eat safely (eating skill) are related, but distinct.

Separating feeding behaviors and eating skills in an assessment allows for clearer understanding of how each construct is contributing to the child’s feeding. In addition, behavior and skill need to be measured on different scales. Although behaviors are measured on a scale related to frequency or severity (e.g., never to always), skills are measured on a scale related to ability to complete a task (e.g., yes, sometimes, not yet). For example, the item “My child opens their mouth when food is offered” assesses an observable behavior by the child in response to food being offered; this item would be measured on a scale from never to always. The item “My child can open mouth wide enough to accept a spoon” assesses the function of the child’s mouth and their ability to open their mouth; this item would be measured on a scale of yes, sometimes, or not yet. Although both of these items assess opening of the mouth, the prior assesses the child’s willingness to open their mouth (i.e., behavior) and the latter assesses the child’s ability to open their mouth (i.e., skill). Similarly, the item “My child is willing to touch food with her hands” assesses the child’s behavioral response to food, whereas the item “My child can grasp a piece of food between thumb and another finger” assesses the child’s fine motor skills that support independent eating. Differentiating between a child’s feeding behaviors and eating skills is critical for appropriately guiding therapies and interventions.

The PediEAT fulfills the need for a tool that assesses feeding behaviors. The purpose of this article is to present the foundational development and content validation of the Child Oral and Motor Proficiency Scale (ChOMPS), a parent-report measure of eating, drinking, and related skills in children between the ages of 6 months and 7 years. These early steps in instrument development are critical prerequisites for preparing an instrument for further psychometric testing (Greenwood & McConnell, 2011). Content validation, which is the degree to which an instrument adequately represents a domain of interest, is one of the most critical steps in instrument development (Beck & Gable, 2001).

Method

The ChOMPS was developed following DeVellis’ guidelines for instrument development (2012) and the PROMIS^® Instrument Development and Validation Scientific Standards (“PROMIS^®,” 2013). Development and content validation of the ChOMPS occurred in four phases: Phase 1—Item Generation; Phase 2—Content Validation With Professionals Using Content Validity Indices (CVI); Phase 3—Content Validation With Parents Using Cognitive Interviews; and Phase 4—Readability Testing. Methods for each of the four phases are discussed below. Institutional review board approval was obtained from the University of North Carolina at Chapel Hill.

Phase 1: Item Generation

Initial items for the ChOMPS were generated with the goal of developing a comprehensive set of items that assess skills related directly to eating as well as foundational skills necessary for supporting the body in a way to facilitate safe, efficient, age-appropriate eating. The ChOMPS was developed using dynamic systems theory as a theoretical lens through which to understand the development of eating skill as a complex, dynamic process that is influenced by past experience and constrained by factors both internal and external to the child (Thelen, 2005). Acknowledging that eating and motor skills may develop along a continuum of less complex to more complex skill, items were developed to assess the full range of possible skills in healthy, typically developing children as well as children with a wide variety of diagnoses between 6 months and 7 years of age.

Initial items were generated from several sources. First, a review of the literature was conducted in CINAHL and PubMed using the following search terms: ((Assess*) OR (Evaluat*)) and ((Feed*) OR (Eat*)) AND (skill). Limits were placed on the search, including English language, full text, human, and 6 months to 7 years of age. To be included in the literature review, the article had to discuss eating skills in children 6 months to 7 years of age or contain a discussion of an assessment tool for evaluation of a child’s eating skills. Further searching of the literature was conducted to identify all articles on the development and testing of the assessment tools identified. In addition to articles, a textbook (Morris & Klein, 2000) that discusses eating skill development in early childhood was used as a reference in generating items. Using the literature and available assessment tools, the authors generated a list of discrete eating skills. Then, through team discussions of the theoretical framework of dynamic systems theory and the range of possible skills across this broad age and developmental range, the initial list of skills identified through the literature and current tools was expanded to generate a comprehensive set of initial items for the ChOMPS.

Phase 2: Content Validation With Professionals Using CVI

After the initial items were generated, items were then validated by a group of professionals with expertise in pediatric feeding using CVI. We aimed to recruit a sample of professionals representing the multiple disciplines that care for children with feeding difficulties, including speech-language pathology, physical therapy, occupational therapy, nursing, and psychology. We purposefully selected and invited a convenience sample of professionals who had an active clinical practice and/or an active presence in research, publishing, or continuing education in pediatric feeding problems. This validation process occurred in two rounds. In both rounds, professionals were sent an email invitation to participate in an anonymous online survey. In the survey, professionals were asked to rate each item for relevance on a 4-point ordinal scale with the following options: 1 = not at all relevant, 2 = somewhat relevant, 3 = moderately relevant, and 4 = highly relevant. Similarly, the professionals were asked to rate each item for clarity on a 4-point ordinal scale with the following options: 1 = not at all clear, 2 = somewhat clear, 3 = moderately clear, and 4 = very clear. The purpose of the CVI testing was to quantify the professionals’ rating of the relevance and clarity of items on the ChOMPS and to identify specific items that needed to be removed or further developed. Participants were invited to provide suggestions on rewording items that they thought were unclear, suggest additional items, and comment on the directions that would be given to parents at the beginning of the tool.

CVIs were calculated at the item level and scale level for both relevance and clarity (Lynn, 1986). Item-level CVI for relevance (I-CVI-R) was calculated as the proportion of professionals who rated the item as moderately or highly relevant. Item-level CVI for clarity (I-CVI-C) was calculated as the proportion of professionals who rated the item as moderately or highly clear (Beck & Gable, 2001). Item-level CVI can range from 0 to 1, with 0 indicating none of the professionals rated the item as being moderately or highly relevant/clear and 1 indicating all of the professionals rated the item as being moderately or highly relevant/clear. For example, if there were 10 professionals, and seven rated an item as being either moderately or highly clear, but the other three professionals rated the item as having no or low clarity, then the I-CVI-C would be calculated as 7/10 or I-CVI-C = 0.7.

With more than six professionals in each round, any item with an I-CVI for either relevance or clarity of less than 0.78 required further review and development (Lynn, 1986). Our interdisciplinary team reviewed the items with I-CVI less than 0.78. Using the qualitative feedback provided by professionals as well as the current literature, the team came to a consensus about whether to revise the item, delete the item, split the item into two separate items, add a new item, or retain the item unchanged.

Scale-level CVI was calculated as the average of the item-level CVI scores for relevance (S-CVI-R) and clarity (S-CVI-C). The acceptable minimum S-CVI was defined as 0.90 (Polit & Beck, 2006). In Round 1, the S-CVI did not meet the minimum threshold of 0.90, thus significant changes were made to the ChOMPS, and a second round of surveys with a different set of professionals was conducted using the same method. In the second round of surveys, purposeful sampling was used to ensure a more diverse sample of professionals representing a variety of disciplines that treat pediatric feeding disorders.

Round 1

Nine pediatric feeding professionals completed the first round of CVI testing of the ChOMPS. Three of these professionals were occupational therapists (OT), and six were speech-language pathologists (SLPs). Three professionals were PhD-prepared and involved in teaching and research. Seven were currently involved in clinical care of patients with feeding or swallowing disorders.

Round 2

Ten pediatric feeding professionals, who did not participate in Round 1, participated in the second round of CVI testing. In the second round of CVI testing, a more diverse sample of professionals participated, including five SLPs, one OT, one advanced practice nurse, two psychologists, and one physiotherapist. Of these 10 professionals, seven were involved in research and six in teaching. Of the eight currently practicing clinically, four were based in an inpatient setting, five in an outpatient setting, three in a community setting, and one in a day treatment setting.

Phase 3: Content Validation With Parents Using Cognitive Interviews

The ChOMPS is a parent-report tool, meaning that parents will be the ones completing the assessment. It is imperative that the tool be written in language understandable by parents, that parents interpret items in the intended manner, and that the items assess skills that are observable by parents with varying levels of knowledge about feeding. Cognitive interviewing is a technique used in instrument development to determine how intended respondents understand, interpret, and make decisions about how to respond to items on a tool (DeWalt, Rothrock, Yount, & Stone, 2007; Knafl et al., 2007). Cognitive interviews were conducted to further establish content validity of the ChOMPS with the intended respondents (i.e., parents).

Parents of children between the ages of 6 months and 7 years, living in the continental United States, were invited to participate in the study by completing both an online survey and a telephone interview. Parents of children with feeding difficulty as well as parents of typically developing children without feeding difficulty were sought to participate and were offered a US$20 online gift card for completing the study. Parents of children with feeding difficulty were recruited from The Feeding Challenges Registry (http://feedingflock.web.unc.edu), an international registry of parents of children with feeding difficulty, which is maintained by our research team. Parents of typically developing children were recruited through an email listserv announcement to the School of Nursing at the University of North Carolina at Chapel Hill and through the The Feeding Challenges Registry, if they had a typically developing child who qualified for the study and had not yet participated. Finally, snowball sampling was utilized by asking interested parents to share the study information with friends and family who may also be interested.

Nineteen parents participated in this phase of development of the ChOMPS. Characteristics of the respondents and their families are provided on Table 1. Seven of these were parents of typically developing children without feeding problems (mean age: 3.6 years, range: 1.5-7 years), and 12 of these parents had a child with some degree of feeding difficulty (mean age: 3.5 years, range: 0.8-6.4 years). The children with feeding difficulty had a variety of coexisting medical conditions, including five with chromosome abnormalities, one with cerebral palsy, three with congenital heart defects, two with autism spectrum disorder, and six with developmental delay.

Table 1.

Demographic Characteristics of Participants in Phase 3 Cognitive Interviews (N = 19).

	n
Parent’s relationship to child
Mother	17
Father	2
Parent education completed
High school or less	2
Technical school/community college	3
College/university or higher education	14
Parent race
Asian	1
Black	2
Hispanic	1
White	15
Family type
Two parent	17
One parent	2
Family income
<US$30,000	4
US$30,000-US$49,999	4
US$70,000-US$89,999	6
>US$100,000	5
State of residence
Massachusetts	2
Minnesota	1
New Hampshire	1
North Carolina	12
Oklahoma	1
Texas	1
Virginia	1

Note. No parent in the sample indicated that their household income was between US$50,000 and US$69,999 or between US$90,000 and US$100,000, so these categories are not included.

First, parents completed an online survey that included basic demographic questions about themselves, their child, and their family, as well as the ChOMPS. Participating parents were asked to complete the ChOMPS questions with their child between the ages of 6 months and 7 years in mind. If a parent had more than one child in this age range, he or she is asked to think about one child when completing the ChOMPS. Parents were asked to flag items on the ChOMPS they found difficult to answer, needed clarification on the meaning, or otherwise wanted to discuss. After completion of the survey, parents were contacted for the telephone interview. In the interview, parents were asked to give feedback on the ChOMPS items and response options and to share their experience completing the tool, their understanding of the directions, and how difficult or easy it was to make decisions about which response option to choose. The interviewer started with ChOMPS items the parent had flagged and then went through each remaining item, asking the parent what they thought the question meant and/or to state the question in their own words. At the conclusion of the interview, the parent was asked to share any other thoughts or concerns and to suggest additional items that they felt were missed.

Interviews were audio recorded. One research team member transcribed the specific words parents used for phrasing of each item and paraphrased any other discussion between the interviewer and participant regarding the item’s response options, directions, items missed, and overall experience taking the ChOMPS. A second research team member verified the transcription for accuracy, and any discrepancies were resolved. A matrix table with parents’ responses was created for analysis with each item in a column and each participant in a row. The research team conducted a systematic column-by-column analysis of the data (Miles & Huberman, 1994) to compare parents’ understanding of the meaning of each item with the intended meaning and parents’ acceptance of the wording of each item. For each item, the team came to a consensus about whether to revise the item, delete the item, split the item into two separate items, add a new item, or retain the item unchanged. If only one parent expressed difficulty with an item, but all others found the item’s wording acceptable and understood the item’s meaning, then the team erred on the side of retaining the item unchanged. The team also decided whether to revise the directions and response options through a consensus process.

Phase 4: Readability Testing

Throughout development and refinement of the ChOMPS items, the team intentionally made decisions about item wording to enhance readability by parents of all educational backgrounds. Short, simple wording and short phrases were used intentionally, examples were given when relevant, and differences between similar items were emphasized. Health literacy literature suggests health-related patient education materials and health-related documents be written at or below a sixth-grade reading level (Roberts, Zhang, & Dyer, 2016). A free online program (www.readability-score.com) was used to generate readability grade levels using the following readability formulas: Flesch–Kincaid, Gunning fog, Coleman–Liau, Simple Measure of Gobbledygook (SMOG), and automated readability index. The average grade level of all of these scores was used to determine the readability of the ChOMPS after each phase of development. During Phase 2, readability testing was conducted after each round of CVI testing.

Results

Phase 1: Item Generation

Using the literature and available assessment tools, 69 items were generated for the initial version of the ChOMPS. Some items were directly related to eating (e.g., “My child can take a bite of a cookie or cracker”), whereas other items were related to foundational skills indicating trunk stability and overall tone (e.g., “My child can sit upright without support”) or skills related to self-feeding (e.g., “My child can use a filled spoon or fork to bring food to mouth.”). All items were prefaced with the phrase My child can followed by the statement of the skill. Using the word can was intentional to direct parents to skill as opposed to behavior.

The response options given were yes, sometimes, and not yet, which was intended to identify established, emerging, and not yet emerging skills. This response option scale is the same as that used in the Ages & Stages Questionnaire^®, Third edition (Paul H. Brookes Publishing, Co.), a validated parent-report developmental screening tool used with children 1 month to 5½ years of age (Squires, Twombly, Bricker, & Potter, 2009).

Phase 2: Content Validation With Professionals Using CVI

Round 1

The S-CVI for relevance was 0.77, and S-CVI for clarity was 0.97. I-CVI for relevance ranged from 0.22 to 1, and I-CVI for clarity ranged from 0.75 to 1. Of the original 69 items, 37 were retained, three items with I-CVI-R < .78 were deleted, 29 items were revised based on suggestions provided by professionals, and four new items were added. An example of a new item that was added based on the suggestion of one professional was “My child can hold a bottle or sippy cup by himself/herself and bring it to mouth.” In this first round, the S-CVI for relevance did not meet the minimum criteria of 0.90; after substantial changes were made to the items after Round 1 of CVI testing, resulting in 70 items, a second round of CVI testing was conducted.

Round 2

The S-CVI for relevance was 0.90, and S-CVI for clarity was 0.96. Eight of the 70 items had either an I-CVI for relevance or I-CVI for clarity of <0.78. Of these eight items, one item was split into two separate items, and two items were revised. For example, the item “My child can keep head steady when seated upright (with or without having their body supported)” was separated into two items because professionals felt that it was important to know whether or not the body was supported. The revised items read, “My child can keep head steady when seated upright with support” and “My child can keep head steady when seated upright without support.”

Five of the eight items with I-CVI < 0.78 were retained based on literature support and some respondents rating the item as highly relevant or clear. For example, the gross motor questions were rated as having low relevance by some professionals, but one professional commented that these questions were highly relevant to eating skills because of the impact of mobility on digestion and elimination functions. In instances where there was disagreement between professionals about the relevance of an item, the research team erred on the side of retaining the item for further evaluation in cognitive interviews with parents and in future psychometric testing. Following revisions based on Round 2 of CVI testing, the ChOMPS had 71 items.

Phase 3: Content Validation With Parents Using Cognitive Interviews

The following changes were made to the ChOMPS based on analyses of cognitive interview data: 36 items were retained, 31 items were revised, two items were split into two separate items, four items were deleted, and one item was added. The revised ChOMPS had 70 items. In some of the retained items, words were underlined to emphasize differences between similar items, as per parents’ suggestion. Revisions made to items focused on using words that parents used, simplifying wording, and adding examples to items where parents indicated it would be helpful. For example, in the item “My child can roll over from front to back,” most parents used the word “tummy” in their rephrasing of the item. This item was revised to read “My child can roll over from tummy to back.” For the item, “My child can grasp a toy or rattle in hand,” we simplified and changed to wording used by parents. This item now reads “My child can hold a toy in hand.” For the item “My child can stand holding on to something,” parents often gave examples of what the child might hold on to when learning to stand. This item was revised to read: “My child can stand holding on to something (such as, a table or couch).”

In addition to the revisions made to the items, the sequence of several items was rearranged to put similar items closer to each other or to have items in order of gradation of difficulty, from least difficult to most difficult. With regard to the response options of yes, sometimes, and not yet, parents commented that these response options “made sense” and that “it was not hard to answer.” One parent of a child with complex health care needs commented that although her daughter was not expected to ever be able to talk due to paralyzed vocal cords, “it was pretty easy to choose between the listed choices.” Several parents commented that they wanted more direction about what to do if their child had not tried a skill yet or was not allowed to eat a specific type of food because of safety. The directions were revised to address these concerns, as well as to emphasize that the ChOMPS is specifically asking about skills (i.e., what they can do) as opposed to behaviors (i.e., what they are willing to do). At the end of Phase 3, there were 70 items on the ChOMPS.

Phase 4: Readability Testing

The average readability of the ChOMPS was below the recommended sixth-grade level at all tested time points. After Phase 1, the average readability grade level was 4.3. After Phase 2 Round 1, the average readability was 5.5. After Phase 2 Round 2, the average readability was 5.4. After Round 3, the average readability was 5.7. Results of the specific readability formulas at each time point are available in Table 2.

Table 2.

Readability Results After Each Phase of Development.

	Phase 1	Phase 2		Phase 3
	Phase 1	Round 1	Round 2	Phase 3
Flesch–Kincaid grade level	2.5	3.9	3.8	4
Gunning fog score	4.8	5.9	5.8	6.4
Coleman–Liau index	6.9	7.8	7.8	7.5
SMOG index	5.5	5.9	5.8	6.4
Automated readability index	2	4	4	4.1
Average grade level	4.3	5.5	5.4	5.7

Note. Results were generated using www.readability-score.com. SMOG = Simple Measure of Gobbledygook.

Discussion

The ChOMPS is the first parent-report assessment of eating, drinking, and related skills in children between 6 months and 7 years of age with evidence of content validity. The ChOMPS was developed following DeVellis’ (2012) instrument development guidelines to create a comprehensive and valid assessment tool. In Phase 1, an initial set of items was created, guided by current literature and a theoretical framework of Dynamic Systems Theory, to measure eating, drinking, and related skills across the developmental stages of eating from introduction of solid food through early childhood.

In Phase 2, this initial set of items was tested for content validity with professionals through two rounds of CVI testing. The ChOMPS is intended for use by professionals to guide clinical practice and research. Incorporating professionals into development of the tool aimed to ensure that the tool would be useful and relevant for this purpose. In the first round of CVI testing, the ChOMPS was found to have low overall scale relevance. This was due to the fact that we had purposely included skills that we considered foundational for eating (e.g., trunk control and gross motor skills) but that some professionals may consider less relevant to eating skills. We considered their reviews carefully and made substantial changes to the ChOMPS based on their feedback. Children with feeding difficulty are cared for by individuals trained in a variety of disciplines, depending on the child’s location and available practitioners. Therefore, in the second round of CVI testing, we aimed for a more diverse group of professionals to obtain a multidisciplinary review of the items. We also provided a more comprehensive introduction to the ChOMPS, which described our approach to intentionally assess oral motor skills as well as fine and gross motor skills that provide a foundation for safe and effective eating. The second round of CVI testing established adequate content validity among professionals. Additional improvements were made to the ChOMPS using this second round of professional feedback.

Although the ChOMPS is designed for use by professionals for clinical practice and research, it is intended to be completed by a parent or caregiver of the child. It is essential to ensure that the ChOMPS is understandable by parents of different educational backgrounds and with different levels of experience with feeding. In Phase 3 of development, we used a diverse group of parents to help us refine the ChOMPS and ensure that the items were written in parent-friendly language, used examples where needed, and addressed skills that they felt capable of assessing. Because parents of children with diagnosed feeding problems often have experience with feeding therapies and the medical vocabulary around feeding, we purposefully interviewed parents of children with and without feeding problems to ensure that all parents were able to interpret questions on the ChOMPS as we intended. Cognitive interviewing is a critical step in development of tools intended for completion by parents, but it is often left out of the tool development process. Parents in this study provided invaluable feedback that improved the ChOMPS substantially. To further ensure readability across educational levels, the ChOMPS is written at a less than sixth-grade reading level. Future directions for further development and testing of the ChOMPS are discussed below.

Limitations

The primary limitation of the research presented in this manuscript was that the sample of professionals in the first round of CVI testing was limited in diversity of disciplinary background. After making significant changes to the ChOMPS, the research team chose to conduct a second round of CVI testing. The team purposefully selected professionals in the second round of CVI testing to ensure more disciplinary diversity. Another limitation was with regards to the sample of parents used for the cognitive interviews. The sample was primarily White, highly educated mothers from two parent families. Also, because the ChOMPS is currently only available in English, all participants were English speaking.

Future Directions

Further validation with diverse samples of parents and translation and cultural adaptation of the tool to different languages will support the use of the ChOMPS across populations. Also, further validation and testing of the ChOMPS with a sample of parents of children with more significant physical disabilities would further support use of the ChOMPS with this population.

Longitudinal studies of the development of eating skills in young children using the ChOMPS are needed to provide important information about early identification of children at highest risk for long-term eating skill delays. In studies on acquisition of other types of motor skills, such as walking, it has been found that most children follow a typical developmental sequence (e.g., crawling on stomach, then crawling on knees, then crawling on hands and feet, then standing up and walking), but some children follow a less typical sequence that remains successful in achieving normal walking (e.g., crawling on stomach, then standing up and walking; Largo, Kunda, & Thun-Hohenstein, 1993). Eating skill development is also a dynamic developmental process characterized by equifinality, meaning that there are likely several different, but viable, paths to functional eating (Ungar, Ghazinour, & Richter, 2013). Most children follow a sequence of eating skill development, such as sucking from the breast or bottle, then eating pureed food from a spoon, then eating chewable foods (Carruth, Ziegler, Gordon, & Hendricks, 2004). Other children may follow a different sequence of skill development that also allows for the successful achievement of complex eating skills. It is valuable to differentiate which patterns of eating skill development support development of later age-appropriate eating and which patterns lead to chronic problematic eating and therefore require early intervention.

Conclusion

The ChOMPS is the first parent-report assessment of eating, drinking, and related skills in young children with evidence of content validation. Subsequent studies have provided evidence of acceptable psychometric properties of the ChOMPS, including internal consistency reliability, test–retest reliability, convergent validity, and known-groups validity (Park, Pados, Thoyre, Estrem, & McComish, 2019). In addition, age-based norm-reference values are now available to guide interpretation of ChOMPS scores (Pados, Thoyre, & Park, 2018a). The ChOMPS can be used in clinical practice to evaluate the gross, fine, and oral motor skills that contribute to a child’s ability to eat safely in an age-appropriate manner. The ChOMPS is not intended to be used as a diagnostic tool and does not replace clinician assessment, but it can be used to augment a clinician’s assessment and provide an objective assessment by the parent, who is most familiar with the child’s eating skills across the course of the day and different settings. This information may be integrated into the evaluation of a child for qualification for early intervention services and may be useful for treatment program outcome reporting. The ChOMPS can also be used in research to evaluate response to interventions and to establish prevalence of eating skill deficits in young children, which is critical for establishing need for service providers, reimbursement, and research funding in this area.

Footnotes

Acknowledgements

We would like to acknowledge the research assistants who helped with this project: Carrie Batchelor, Leah Baumgart, Amy Pope, Megan Pryzbyla, and Lauren Rafeek.

Declaration of Conflicting Interests

The author(s) declared no potential conflicts of interest with respect to the research, authorship, and/or publication of this article.

Funding

The author(s) disclosed receipt of the following financial support for the research, authorship, and/or publication of this article: This research was supported in part by the Francis Hill Fox Distinguished Term Professorship Fund.

ORCID iD

Britt F. Pados

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