Abstract
Background
While there are studies evaluating the eating behaviors of children with cerebral palsy (CP) and the eating attitudes of mothers, studies on eating behaviors and mothers’ eating attitudes in children with CP with cerebral visual impairment (CVI) according to visual function level are in their infancy. Based on this, the aim of this study was to compare eating behaviors and mothers’ eating attitudes according to the level of visual function in children with CP and CVI.
Methods
A total of 90 children with CP and CVI aged 36–72 months, consisting of 30 level 2, 30 level 3 and 30 level 4 according to the visual function classification system (VFCS) and their mothers participated in the study. Eating behaviors of children with CP and CVI were assessed with the Children’s Eating Behavior Questionnaire (CEBQ) and mothers’ eating attitudes towards the feeding process of their children were assessed with The Mother’s Attitudes Towards the Feeding Process Scale (MAFPS).
Results
According to the results of the study, statistically significant differences were found among the three groups in all subdomains of the CEBQ—except for the emotional overeating subdomain—and in all subdomains and the total score of the MAFPS (p < 0.001). There was no statistically significant difference between the groups in the emotional overeating sub-field of CEBQ (p = 0.184). In the post hoc analysis, a statistically significant difference was found in all assessment areas except the emotional overeating area in the pairwise comparisons of the groups (p < 0.05).
Conclusion
In the study in which eating behaviors of children diagnosed with CP and CVI and eating attitudes of mothers were evaluated according to VFCS levels, it was determined that children at level 4 and their mothers exhibited a more negative picture compared to level 3, and children at level 3 and their mothers exhibited a more negative picture compared to level 2. Worsening vision was found to be a factor that negatively affected the eating behaviors of children with CP and CVI and the mothers’ attitudes towards eating. The eating behaviors of children with CP and CVI and the eating attitudes of mothers should be included in routine assessments and intervention approaches that include mothers in this process should be planned.
Graphical Abstract
Keywords: Cerebral visual impairment, Cerebral palsy, Feeding problems, Eating behavior, Mother’s eating attitude
Introduction
Cerebral palsy (CP) is a neurodevelopmental disorder caused by brain injury due to a lack of oxygen before, during, or after birth [1]. Children with CP may experience cognitive, motor, sensory processing, vision, language, hearing, psychosocial, behavioral, sleep and nutritional problems depending on the severity and location of brain damage [2–4]. One of these problematic areas, visual impairment, occurs in 60–70% of children with CP [5]. Visual problems that occur in children with CP due to damage to the central nervous system are called cerebral visual impairment (CVI). CVI occurs as a result of lesions in the areas beyond the lateral geniculate nucleus of the thalamus, especially in the parieto-occipitotemporal system [6]. Due to this effect, functional vision-related deficiencies such as visual spatial, visual motor, visual discrimination, color perception, visual acuity and contrast sensitivity can be observed in children with CP and CVI [7, 8].
Approximately 70–80% of the receptors in the human body are vision receptors, and therefore vision is of great importance in terms of perception of the body and the environment [9]. The role of vision is not limited to the perception of visual stimuli, but it also plays a fundamental role in the processing of vestibular, tactile, taste and smell sensations; the development of motor skills; and the maintenance of mobility, activities of daily living and self-care [10]. The texture, taste, odor, and appearance of foods constitute the sensory parameters of nutrition. Vision contributes to the integration of these sensory cues and helps individuals form expectations about the properties of food, such as safety, flavor, and palatability. In children with CVI, difficulties in visual-sensory integration may hinder the recognition of familiar foods, interfere with reaching and grasping, and alter food preferences. These challenges can result in food selectivity, food refusal, oral defensiveness, or prolonged mealtime behavior [11, 12].
Problems related to eating processes seen in children with CP can become a difficult process not only for the children but also for their mothers, who are generally the primary caregivers [13]. Although no study was found to examine the attitudes of mothers of children with visual impairment regarding their children’s eating process, it has been revealed in the literature that children with CP experience eating problems and that these situations are a difficult process for mothers [14–16]. Arslan et al. concluded that mothers faced challenges in the feeding process due to problems in chewing and solid food intake among children with CP [17]. Another study found that eating behavior problems in children with CP caused serious anxiety and stress in mothers [15]. Adams and colleagues determined that the behavior of children with CP during the eating process caused mothers to exhibit inappropriate attitudes [16].
There are limited studies in the literature examining areas other than visual skills in children with CP and CVI. In these studies, sensory processing skills, motor skills, social and emotional status, and eating behavior of children with CP with and without CVI were compared [11, 18, 19]. However, when the literature was examined, no study was found in which eating behavior and the mother’s attitude in the process of feeding her child were examined according to the level of visual function in children with CP and CVI. Based on this, the aim of the study was to compare eating behaviors and mothers’ eating attitudes according to visual function levels in children with CP and CVI.
The hypotheses of the study are as follows:
H0-1: There is no difference in eating behaviors of children with CP and CVI according to visual function level.
H0-2: There is no difference in the attitudes of mothers towards the eating process of their children according to the visual function levels of children with CP and CVI.
Materials and methods
Study design
Permission for the study was obtained from the Lokman Hekim University Scientific Research Ethics Committee. The ethical approval was granted by this institution because the principal investigator was affiliated with Lokman Hekim University during the study planning and protocol development phase. The study was conducted at a special education center in Ankara, where low-vision rehabilitation programs are regularly implemented. Participants were recruited from this center and through the snowball sampling method between June and December 2024. The inclusion process involved contacting families of children diagnosed with CP and CVI who met the eligibility criteria. Written informed consent was obtained from all mothers prior to data collection. All study procedures were carried out in accordance with the ethical standards of the Declaration of Helsinki.
Children with CP and CVI and their mothers participated in the study. The children were classified into three groups (levels 2, 3, and 4) according to the Visual Function Classification System (VFCS). The study compared the eating behaviors of children with CP and CVI and the feeding attitudes of their mothers across these VFCS levels.
Participants
The sample size of the study was determined using the G*Power 3.1.2.7 software (Universität Düsseldorf, Psychologie). An a priori power analysis was performed within the F-test family by selecting the “ANOVA: Fixed effects, omnibus, one-way” model. Based on data variability reported for the Children’s Eating Behavior Questionnaire (CEBQ) in preschool populations, the analysis was conducted using a significance level of α = 0.05, a statistical power of 1–β = 0.80, three comparison groups, and an anticipated Cohen’s f = 0.35 (medium effect size). Under these parameters, the minimum required total sample size was calculated as 81 participants (27 per group).
The children who participated in the study were included in the study based on the diagnoses of CVI and CP in the reports they received from the hospital during the initial diagnosis process. Then, children with CP and CVI were classified as level 2, 3 and 4 based on the VFCS and three groups were formed. Children aged between 3 and 6 years, diagnosed with CP with CVI, and whose eating activities were carried out by their mothers were included in the study. Exclusion criteria were having uncontrolled epileptic attacks and having another chronic or neurodevelopmental disease other than CP with CVI. The inclusion criterion for mothers of children with CP and CVI was to be at the communication and cognitive level to answer the scales. Mothers with an advanced stage of a chronic disease (such as psychiatric, cancer, neurological, orthopedic and systemic diseases) were excluded from the study. The presence of chronic illness was verified through self-report based on a brief health status question included in the sociodemographic information form, and no participants reported having any of these conditions.
In the study, children with CP and CVI who met the inclusion criteria and were classified as VFCS levels 2, 3, and 4 were evaluated. A total of 96 children with CP and CVI (32 at VFCS level 2, 31 at VFCS level 3, and 33 at VFCS level 4) were initially included in the study. However, six children (two from VFCS level 2, one from VFCS level 3, and three from VFCS level 4) were excluded because they did not complete all assessments. Thus, the study was completed with 90 children with CP and CVI, including 30 in each VFCS level. All mothers of these children met the inclusion criteria and completed the evaluations in full.
Data collection tools
A sociodemographic data form was used to collect descriptive data. Functional vision levels of children with CP and CVI were assessed with VFCS and eating behaviors were assessed with CEBQ. Mothers’ attitudes about their children’s eating process were assessed with The Mother’s Attitudes Towards the Feeding Process Scale (MAFPS). All VFCS evaluations were conducted by a single researcher (MC) experienced in assessing children with CP and CVI. As both the CEBQ and MAFPS are self-report instruments, the forms were completed directly by the mothers. All assessments took approximately 20 min.
Sociodemographic information form
This form collects age, gender and CP type information of children with CP and CVI, and age information of mothers.
Visual function classification system (VFCS)
The VFCS was developed by Rosenbaum et al. to categorize visual performance in individuals with CP and is used between the ages of 1–19 years [20]. This classification system divides vision into five levels. Level 1: The visual function is used easily and successfully in vision-related activities. Level 2: Visual function is used successfully but self-initiated compensatory strategies are needed. Level 3: Visual function, used but needs some adaptations. Level 4: Visual function is used in highly adapted environments but only some of the vision-related activities can be performed. Level 5: Visual function is not used even in highly adapted environments. Functional visual ability worsens from level 1 to level 5. The Turkish reliability validation of the VFCS was conducted by Tat et al. and the inter-rater reliability coefficient (ICC = 0.974) was found [21].
Children’s eating behavior questionnaire (CEBQ)
The CEBQ, developed by Wardle et al. for children aged 2–7 years, is a 35-item, 5-point Likert-type questionnaire (1 = never, 5 = always) answered by parents [22]. The questionnaire has 8 sub-dimensions consisting of food responsiveness, emotional overeating, enjoyment of food, desire to drink, satiety responsiveness, slowness in eating, emotional undereating and food fussiness. Each subscale is evaluated separately. In the first four subscales (food responsiveness, emotional overeating, enjoyment of food, desire to drink), lower scores indicate decreased appetite and reduced interest in eating, which reflect unfavorable eating behaviors. Conversely, in the last four subscales (satiety responsiveness, slowness in eating, emotional undereating, food fussiness), higher scores indicate reduced food intake, selective eating, or difficulties in regulating eating, representing negative eating behavior patterns. Turkish reliability and validity were conducted by Yılmaz et al. in 2011 on children aged 2–9. Cronbach alpha coefficients of eight sub-dimensions ranged from 0.74 to 0.91 [23].
The mother’s attitudes towards the feeding process scale (MAFPS)
MAFPS was developed by Dilsiz and Dağ in 2015 to measure the feelings, thoughts and approaches of mothers with children between 9 and 72 months of age regarding the feeding process [24]. The scale consists of 27 questions and the answers are evaluated on 5 points (1 = never, 5 = always). MAFPS consists of five dimensions named as the negative affect during meal, attitudes about insufficient/unbalanced feeding, negative feeding strategies, forced feeding, and reaction to the viewpoints of others. The total score that can be obtained from MAFPS varies between 27 and 135. The total score ranges from 27 to 135, and higher scores indicate more negative attitudes and greater difficulties experienced by mothers in the feeding process. In the reliability and validity analysis, the Cronbach Alpha value of the scale was found to be 0.91 and the test-retest reliability coefficient was found to be 0.94 [24].
Data analysis
SPSS Statistics IBM Version 26.0 program was used for the statistical analysis of the data. The suitability of the data for normal distribution was evaluated using Skewness–Kurtosis values (± 2.0 range accepted as normal), histogram inspection, the Kolmogorov–Smirnov test (p < 0.05 indicating non-normality), and the coefficient of variation ratio. As a result, it was determined that the data were not normally distributed, and nonparametric tests were used in the analysis. Descriptive data were expressed as number (n) and percentage (%) for categorical variables, and median and interquartile range (IQR) for numerical variables. For the comparison of categorical variables among the three VFCS groups, the Chi-square test was used, while the Kruskal–Wallis test was used for numerical variables. The comparisons of CEBQ and MAFPS results among VFCS levels were analyzed using the Kruskal–Wallis test, and when significant differences were observed, Bonferroni correction was applied for pairwise comparisons to identify the source of the difference while controlling for Type I error due to multiple testing. Effect sizes (η²) were also calculated for the Kruskal–Wallis analyses to indicate the magnitude of between-group differences. For η², values below 0.01 are defined as negligible effects, values between 0.01 and 0.06 are defined as small effects, values between 0.06 and 0.14 are defined as medium effects, and values above 0.14 are defined as large effects [25]. Statistical significance was accepted as p < 0.05.
Results
No statistically significant difference was found between the groups created according to VFCS level of children with CP and CVI in terms of age (p = 0.257), gender (p = 0.733) and affected area (p = 0.833). The age range of the mothers of children with CP and CVI was 25–40 years, and no statistically significant difference was found between the groups in terms of mothers’ age (p = 0.210) (Table 1).
Table 1.
Descriptive data of children with CP and CVI and their mothers
| Children with CP and CVI | ||||
|---|---|---|---|---|
| VFCS level | Level 2 | Level 3 | Level 4 | |
| n = 30 | n = 30 | n = 30 | ||
|
Median
(% 25–75 IQR) |
Median
(% 25–75 IQR) |
Median
(% 25–75 IQR) |
p | |
| Age of children (month) | 43 (41-50.25) | 46 (42.75-52) | 46 (42-52.25) | a 0.257 |
| Age of mothers (years) | 31 (29–35) | 31 (28.75-32) | 32 (30–35) | a 0.210 |
| Gender | n (%) | n (%) | n (%) | p |
| Girl | 13 (43.3) | 16 (53.3) | 15 (50) | b 0.733 |
| Male | 17 (56.7) | 14 (46.7) | 15 (50) | |
| CP type | n (%) | n (%) | n (%) | p |
| Hemiparetic | 14 (46.7) | 12 (40) | 13 (43.3) | b 0.873 |
| Quadriparetic | 16 (53.3) | 18 (60) | 17(56.7) | |
CVI, Cerebral visual impairment, CP Cerebral palsy, VFCS Visual Function Classification System, IQR Interquantile range, n Number of children, % percentage
aKruskal Wallis test, bChi Square test, p < 0.05
A statistically significant difference was found among the VFCS groups of children with CP and CVI in all subdomains of the CEBQ except emotional overeating (p < 0.05). No significant difference was observed between the groups in terms of emotional overeating (p = 0.184). Children with CP and CVI at VFCS level 4 demonstrated lower food responsiveness, enjoyment of food, and desire to drink, while showing higher satiety responsiveness, slowness in eating, emotional undereating, and food fussiness compared to those at level 3. Similarly, children at level 3 exhibited less adaptive eating behaviors than those at level 2. These findings indicate that among children with CP and CVI, as the severity of visual functional limitation increases, appetite decreases and eating behavior problems become more pronounced. Effect size analyses revealed large clinical effects across all CEBQ subdomains except emotional overeating (η² = 0.25–0.32). These results suggest that the reduction in visual functioning significantly and clinically impairs eating behaviors in children with CP and CVI (Table 2).
Table 2.
Comparison of CEBQ sub-domains and MAFPS and sub-domains results between groups
| Children with CP and CVI | |||||
|---|---|---|---|---|---|
| VFCS Level | Level 2 | Level 3 | Level 4 | p | η² |
| N = 30 | N = 30 | N = 30 | |||
|
Median
(% 25–75 IQR) |
Median
(% 25–75 IQR) |
Median
(% 25–75 IQR) |
|||
| CEBQ | - | - | - | - | |
| Food responsiveness | 8.5 (6.75-11) | 6.5 (5.75–8.25) | 5 (5–6) | < 0.001 | 0.29 |
| Emotional overeating | 4 (5–6) | 4 (4–5) | 4 (4–5) | 0.184 | 0.02 |
| Enjoyment of food | 9 (7.5–12) | 8 (5–9) | 6 (6-6.25) | < 0.001 | 0.27 |
| Desire to drink | 8 (7–9) | 6.5 (5–8) | 5 (4–6) | < 0.001 | 0.32 |
| Satiety responsiveness | 9 (7.75-12) | 12 (9–13) | 13 (12–15) | < 0.001 | 0.26 |
| Slowness in eating | 5 (4–5) | 7 (5–8) | 8 (7–9) | < 0.001 | 0.25 |
| Emotional undereating | 5.5 (5-7.25) | 8 (7–9) | 9 (8-11.25) | < 0.001 | 0.28 |
| Food fussiness | 5 (4–6) | 6 (5–8) | 8 (6.75-9) | < 0.001 | 0.32 |
| MAFPS total score | 37 (35-40.25) | 46 (43-49.25) | 57 (52.75–59.25) | < 0.001 | 0.38 |
| The negative affect during meal | 9 (7–10) | 11 (12–15) | 13 (12–15) | < 0.001 | 0.28 |
| Attitudes about insufficient/unbalanced feeding | 9.5 (8–12) | 12 (10.75-15) | 14 (12.75-16) | < 0.001 | 0.32 |
| Negative feeding strategies | 8 (6–9) | 9 (8–10) | 10.5 (9-12.25) | < 0.001 | 0.23 |
| Forced feeding | 5.5 (5–6) | 7 (5.75-8) | 9 (6–11) | < 0.001 | 0.27 |
| Reaction to the viewpoints of others | 5.5 (5–6) | 7 (5–8) | 8.5 (7.75-10) | < 0.001 | 0.26 |
CVI, Cerebral visual impairment, CP Cerebral palsy, VFCS Visual Function Classification System, CEBQ Children’s Eating Behavior Questionnaire, MAFPS The Mother’s Attitudes Towards the Feeding Process Scale, IQR Interquantile range, n Number of children. Kruskal Wallis Test, η²: Eta Square, p < 0.05
A statistically significant difference was found among the groups in the total and subscale scores of the Mother’s Attitudes Towards the Feeding Process Scale (MAFPS) (p < 0.05). Mothers of children with CP and CVI at VFCS level 4 reported higher negative affect during meals, greater use of coercive feeding strategies, and stronger concerns regarding insufficient or unbalanced nutrition compared with mothers at level 3. Similarly, mothers at level 3 displayed less adaptive and more stress-related attitudes toward the feeding process than mothers at level 2. These findings indicate that as the severity of visual functional limitation increases, mothers experience greater emotional distress and anxiety during feeding interactions, making the feeding process more challenging. Effect size analyses revealed large clinical effects across MAFPS total and subscale scores (η² = 0.23–0.32), suggesting that reduced visual function in children with CP and CVI has a clinically significant negative impact on maternal feeding attitudes (Table 2).
Statistically significant differences were found between the groups formed according to VFCS levels in all pairwise comparisons for the CEBQ subdomains (except emotional overeating) and for the MAFPS total and subdomain scores (p < 0.05). These findings indicate a gradual pattern across VFCS levels, suggesting that as visual function decreases, both children’s eating behaviors and mothers’ feeding attitudes become progressively less adaptive. According to the Bonferroni-adjusted pairwise comparisons, significant differences were identified between levels 4–3, 3–2, and 4–2 (p < 0.05). Children with CP and CVI at level 4 demonstrated less adaptive, more restrictive, and more selective eating behaviors compared with those at levels 3 and 2, while children at level 3 exhibited less adaptive eating behaviors than those at level 2. No difference was observed between the groups in terms of emotional overeating (p = 0.184). Similarly, statistically significant differences were found in the MAFPS results (p < 0.05). Mothers of children with CP and CVI at level 4 showed greater stress, negative affect, and control-oriented behaviors during feeding compared with mothers of children at levels 3 and 2, whereas mothers at level 3 exhibited less adaptive and more anxious feeding attitudes compared with those at level 2. These results indicate that, in parallel with the decrease in visual function, a progressive pattern of deterioration showing a linear trend emerges in both children’s eating behaviors and mothers’ feeding attitudes (Table 3).
Table 3.
Results of pairwise comparisons between groups of CEBQ subdomains and MAFPS and its subdomains in children with CP and CVI
| Children with CP and CVI | |||
|---|---|---|---|
| VFCS level | Level 2–3 | Level 2–4 | Level 3–4 |
| CEBQ | - | - | - |
| Food responsiveness | 0.021 | < 0.001 | 0.047 |
| Emotional overeating | - | - | - |
| Enjoyment of food | 0.048 | < 0.001 | 0.039 |
| Desire to drink | 0.036 | < 0.001 | 0.032 |
| Satiety responsiveness | 0.049 | < 0.001 | 0.047 |
| Slowness in eating | 0.001 | < 0.001 | 0.040 |
| Emotional undereating | 0.011 | < 0.001 | 0.019 |
| Food fussiness | 0.048 | < 0.001 | 0.002 |
| MAFPS total score | < 0.001 | < 0.001 | < 0.001 |
| The negative affect during meal | 0.021 | < 0.001 | 0.035 |
| Attitudes about insufficient/unbalanced feeding | 0.003 | < 0.001 | 0.025 |
| Negative feeding strategies | 0.018 | < 0.001 | 0.036 |
| Forced feeding | 0.049 | < 0.001 | 0.042 |
| Reaction to the viewpoints of others | 0.030 | < 0.001 | 0.030 |
CVI Cerebral visual impairment, CP Cerebral palsy, VFCS Visual Function Classification System, CEBQ Children’s Eating Behavior Questionnaire, MAFPS The Mother’s Attitudes Towards the Feeding Process Scale, n Number of children, Bonferroni correction, p < 0.05
Discussion
The findings of this study indicate that reductions in visual function significantly affect both the eating behaviors of children with CP and CVI and the feeding attitudes of their mothers. As visual function limitations increased, children exhibited lower levels of food responsiveness, enjoyment of food, and desire to drink, while their satiety responsiveness, slowness in eating, food fussiness, and emotional undereating tendencies increased. This pattern suggests that visual impairment exerts a marked influence on appetite regulation and the emotional aspects of eating behavior. In parallel, mothers demonstrated less adaptive, more controlling, and anxiety-driven attitudes toward the feeding process of their children. These results reveal that visual function is not merely a sensory parameter but also a key determinant of the psychosocial and behavioral dynamics underlying the feeding process. The gradual and parallel pattern observed in children with CP and CVI and their mothers clearly demonstrates the impact of visual function level on the quality of the feeding process.
The sense of sight is of primary importance among all the senses in terms of the perception of the body, objects and the environment and the organization of behavior [9]. It is stated that social, emotional and behavioral problems may occur in visually impaired children when their independence in daily life activities such as self-care, eating, play and social life is restricted due to visual impairment [18, 19, 26]. Kılıç et al. found that children with CP and CVI had worse emotional and behavioral states than children with CP without CVI. In this study, it was determined that the presence of a vision problem negatively affected the mental health and behavior of children [18]. In addition to general behavioral difficulties, previous studies have also reported that visually impaired children may experience specific challenges in eating behavior, such as food refusal and prolonged mealtime duration [27, 28]. Kawecka et al. found that in addition to the sensory, motor and behavioral skills of the child, factors such as the mothers’ attitude and method of feeding also affect this situation [29]. It has been stated that vision acts as an auxiliary sense in many of the stages of eating activity and that the appearance of food and visual perception of food are important in the acceptance of food [30]. Smyth et al. found that vision problems negatively affect children’s feeding process and that strategies to facilitate eating activity are important for the development of children’s food acceptance [31]. Clark et al. concluded that children with visual impairment had problems in food acceptance and that food selectivity decreased and food acceptance increased in children with eating routine intervention [32]. In another study, it was reported that children with CP and CVI were more problematic in terms of eating behavior and showed more sensory oral sensitivity than children with CP without CVI. In addition, this study found that oral defense and eating behavior problems increased with increased oral sensitivity in children with CP and CVI [19]. In our study, according to the visual classification level, it was found that children with CP and CVI at level 4 exhibited more difficulties in eating behavior subdomains such as food responsiveness, enjoyment of food, desire to drink, satiety responsiveness, slowness in eating, emotional undereating, and food fussiness compared to those at level 3. It was determined that children with CP and CVI at level 3 similarly exhibited more negative behaviors in these areas compared to children with CP and CVI at level 2. No difference was found between the groups in terms of emotional overeating. This result can be explained by the fact that visual skills play an important role in the recognition, perception, selection and acceptance of foods. It is thought that increasing functional visual impairment may be a risk factor that negatively affects children’s eating behaviors. It can be said that reduced visual ability in children with CP and CVI reduces the ability to perceive the texture, taste, smell and appearance of food in a holistic manner. The absence of emotional overeating in this population may therefore reflect the predominant feeding challenges in CP and CVI, such as oral–motor dysfunction and prolonged meal duration, rather than hedonic or stress-driven over-eating patterns established in other populations [33, 34]. This situation may vary for each disability group; therefore, studies examining the related factors for specific disability groups are needed to comment on this result.
Mothers who play a primary role in the feeding of their children with CP may experience anxiety due to difficulties in their children’s eating activities during feeding times [15]. Studies in the literature have shown that mothers who cannot apply the correct feeding method to their disabled children may become more stressed and angry and end the feeding period earlier or later than necessary [35, 36]. Arslan et al. found that the inability of children with CP to consume chewable tissues caused feeding behavior problems in children and negative perceptions of these behaviors in parents [37]. In their qualitative study, Donkor et al. reported that mothers of children with CP reported that it was difficult for them to prolong eating time due to their children’s inadequacies in motor skills [38]. In another study, it was found that mothers engaged in aggressive and violent behaviors against their children due to their decreased patience in the process of feeding their children. In addition, it was determined that mothers may resort to force feeding and inappropriate feeding methods due to children’s refusal of food [16]. On the other hand, it has been reported that force feeding, which is sometimes preferred by mothers, may lead to increased gag reflex and oral defense in children [19] Taylor et al. reported that the involvement or lack of support of other family members in the feeding process of children with CP negatively affected the feeding process of mothers’ children [39]. It is known that visually impaired children have difficulties in the eating process due to their difficulty in recognizing foods [32]. At the same time, it was found that the negative psychological effects experienced by mothers increased with the increase in the severity of visual impairment of children with visual impairment [40]. In our study, it was found that mothers of children with CP and CVI at level 4 were more problematic than mothers of children with CP and CVI at level 3, and mothers of children with CP and CVI at level 3 were more problematic than mothers of children with CP and CVI at level 2 in the general attitude towards the feeding process and in the sub-fields of the negative affect during meal Attitudes about insufficient/unbalanced feeding, negative feeding strategies, forced feeding, and reaction to the viewpoints of others. Poorer nutritional attitudes of mothers of children with more functional vision problems may be associated with increased visual impairment in children. This finding suggests that deficits in functional vision skills not only negatively affect the eating behaviors of children with CP and CVI, but also increase the difficulties faced by mothers in managing feeding processes. This situation reveals the need for more comprehensive support and interventions for both the child and the mothers in the feeding processes of children with high visual impairment.
Limitations
The limitations of the study were that the children with CP and CVI who participated did not have a single CP type, food consumption records were not taken, and food contents were not analyzed. In addition, since the data on children’s eating behaviors and mothers’ feeding attitudes were based on self-report measures, there is a potential risk of response bias and social desirability influence. Psychological and socio-cultural factors such as maternal anxiety, depression, stress, economic status, and social support—which may influence maternal feeding attitudes—were also not assessed, as the study was specifically designed to compare eating behaviors and maternal attitudes according to visual function levels. Future studies should include these psychological and contextual parameters together with visual function to provide a more comprehensive understanding of the feeding process in children with CP and CVI. Moreover, future research should focus on identifying the factors contributing to eating behavior problems through qualitative analyses and food consumption monitoring. Randomized controlled intervention studies may also be conducted, in which feeding interventions are applied to children with eating difficulties and feeding attitude strategies are taught to their mothers or caregivers. Training programs led by health professionals for mothers/caregivers on attitudinal and behavioral feeding strategies are recommended to promote independent and appropriate eating skills in children with CP and CVI.
Conclusion
In the study, it was found that worsening of functional visual skills was a factor that negatively affected both the feeding behavior of children with CP and CVI and the attitude of mothers towards the feeding process. Eating process assessment in children with visual impairment should be done routinely, taking into account the visual level of the child, involving mothers/caregivers, and individualized intervention approaches should be planned for both the child and the mothers/caregivers. In solving the feeding behavior problems in children with CP and CVI, the follow-up of a multidisciplinary team consisting of ophthalmologists, dietitians, occupational therapists, physiotherapists and psychologists may be useful.
Acknowledgements
We would like to thank all participants who participated in the research.
Clinical trial number
Not applicable.
Abbreviations
- CEBQ
Children’s Eating Behavior Questionnaire
- CP
Cerebral Palsy
- CVI
Cerebral Visual Impairment
- MAFPS
Attitudes Towards the Feeding Process Scale
- VFCS
Visual Function Classification System
Authors’ contributions
Conceptualization and methodology: ÖC, ÖE and MC; Data collection: MC; Data analysis: ÖC; Article writing and editing: ÖC, ÖE and MC.
Funding
This research received no external funding.
Data availability
The data presented in this study are available on request from the corresponding author due to privacy and ethical restrictions.
Declarations
Ethics approval and consent to participate
Approval was obtained from the Lokman Hekim University Scientific Research Ethics Committee for the study (Registration Number: 01–08 / Approval Date: 29 May 2024).
Informed written consent was obtained from all participants (obtained from the legal heir for children).
Consent for publication
Written consent was obtained from the patients for publication of the article.
Competing interests
The authors declare no competing interests.
Footnotes
Publisher’s note
Springer Nature remains neutral with regard to jurisdictional claims in published maps and institutional affiliations.
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Associated Data
This section collects any data citations, data availability statements, or supplementary materials included in this article.
Data Availability Statement
The data presented in this study are available on request from the corresponding author due to privacy and ethical restrictions.