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. 2013 Aug 8;7:425. doi: 10.3389/fnhum.2013.00425

Table 1.

Tabulation of studies investigating the effects of breakfast on behavior at school in children and adolescents.

Authors, year Design Sample BF intervention/assessment of BF Assessment of behavior Reported results
Kaplan et al. (1986) RM randomized acute experimental study. Double blind. Behavior treatment center (USA). n = 9 aged 9–13 years. Behavior problems:

  1. High sugar BF

  2. Low sugar aspartame sweetened BF

 In-class observation, +30–60 min post ingestion. No significant difference in behavior due to high or low sugar BF.
Behavior problems: n = 5 ADD-H group:

  1. High sugar BF + Methylphenidate

  2. Low sugar aspartame sweetened BF + Methylphenidate

  3. High sugar BF + placebo

  4. Low sugar aspartame sweetened BF + placebo

 Behavior coded: on-task during 30 min observation.
ADD-H: n = 4. BF of either high or low sugar, not matched for energy. Good inter-rater reliability.
Stratified by behavior problems/ADD-H Conners Teacher Rating Scale hyperactivity index.
Milich and Pelham (1986) RM randomized acute experimental study. Double blind. Behavior treatment center (USA). n = 16, male children mean age 6–9 years, diagnosed ADD-H. Two conditions: Drink at 0800 h

  1. High sugar: 50 g sugar drink

  2. Low sugar: 0 g sugar drink + 175 mg aspartame

 Three observations in two settings.

  1. In-class observation via one way mirror. Behavior coded: on-task, class points, questions correct, and questions attempted for set tasks.

  2. Structured recreational observation (1). Behavior coded: rule adhering, positive peer interaction, noncompliance, negative verbalization.

  3. Structured recreational observation (2). Behavior coded: Positive/negative/neutral interaction.

 No significant effects of treatment on behavior in both settings.
Good inter-rater reliability.
Conners Teacher Rating Scale inattention/over-activity and aggression scales.
Rosen et al. (1988) RM acute experimental study. Double blind. Two schools (USA). n = 45. Three conditions: Standard BF and 113 g drink of differing sugar content:

  1. High sugar: 50 g sugar drink + BF (489 Kcal/90.8 g CHO)

  2. Low sugar: 6.25 g sugar drink + BF (314 Kcal/47 g CHO)

  3. Control: 0 g sugar drink sweetened with aspartame (291 Kcal/41 g CHO)

 In-class and free play observation +30 min post BF.

  1. Preschool: Free play observation. Behavior coded: Fidget, activity change, movement, vocalization, aggression.

  2. Primary school. In-class observation. Behavior coded: Fidget, on-task.

 No significant effects of sugar on behavior in both settings. Significant increase in Conners Teacher Rating Scale hyperactivity index in high sugar condition compared with low sugar condition.
Preschool: N = 30, mean age: 5 years 4 months. Standard BF: 198 g oats, 170 g whole milk, bread (1 slice), 1 tsp margarine, 1 tsp grape jelly (287 Kcal) Time sampling. Good inter-rater reliability.
Male: 66%, Female: 33% Primary school: n = 15, mean age: 7 years 2 months. Male: 40%, female: 60% Middle-High SES. Conners Teacher Rating Scale 10-item hyperactivity index Global rating scale completed by teachers.
Richter et al. (1997) SBP evaluation. Pre-post test design. 6-week intervention. Two primary schools (South Africa). n = 108. Two conditions:

  1. SBP: 30 g Cornflakes, 100 ml semi-skimmed milk, banana (≈267.4 Kcal/1117.8 K)

  2. Control: No SBP

 Video recorded in-class observation following habituation. Significant decrease in off-task and out of seat behavior in SBP group from pre- post intervention. No change in control group.
Male: 50%, Female: 50% Control: n = 55 well-nourished children mean age ± SD: 8.3 ± 0.8. Behavior coded: on-task, off-task, passive-active, positive, or negative peer interaction, class participation, out of seat, request attention, unclear/out of view. Significant increase in activity and class participation in SBP group from pre-post intervention. No change in control group. Significant decline in on-task behavior in control group from pre-post test. No change in SBP group. No significant change in request attention, negative peer interaction, and passive behavior. Hyperactivity subscale scores declined significantly in intervention group from pre-post test.
Intervention: n = 53 undernourished children mean age ± SD: 10.5 ± 1.9. Time sampling.
ADD-H Comprehensive Teacher's Rating Scale 24-item. Teacher completed four subscales for classroom behavior: attention, hyperactivity, social skills, and oppositional behavior.
Chang et al. (1996) RM randomized acute experimental study. Four primary schools (Jamaica). n = 113, Male: 50%, Female: 50% Undernourished (< −1 SD weight-for-age NCHS): n = 57, mean age ± SD: 9.68 ± 0.42. Two conditions:

  1. In-class BF before school: 68 g bread, 28 g cheese, 227 g chocolate milk (520 Kcal)

  2. Low energy control: 68 g orange (18 Kcal)

 In-class observation at ≈0900–1130 h. Two “mock” classroom situations:

  1. Active teaching (2 × 30 min)

  2. Set task (2 × 30 min)

 Significant school × treatment interaction for active teaching on-task, talks, and gross motor behavior and for set task on-task behavior. Significant increase in on-task behavior and decrease in gross motor behavior following BF during active teaching in well-equipped school. Significant increase in talking to peers during active teaching and decrease in on-task behavior during set task in poorly equipped schools following BF. No significant effects of nutritional group and treatment.
Nourished: n = 56, mean age ± SD: 9.18 ± 0.77. Behavior coded: On-task, talking to peers, gross motor, class participation.
Time sampling. Acceptable-good inter-rater reliability.
Bro et al. (1994) SBP evaluation. Pre-post test. 20-day intervention. Vocational secondary school (USA) n = 10 males aged 14–18 years. High rate of off-task behavior at baseline. Two conditions:

  1. Teacher led in-class SBP Nutritionally balanced

  2. No SBP

 In-class observation conducted by teacher. Increase in on-task behavior post SBP compared to baseline.
Low SES. Behavior coded: on-task.
Time sampling. Good inter-rater reliability.
Bro et al. (1996) SBP evaluation. Pre-post test. 9-day intervention. Vocational and learning center (USA): n = 18, aged 15–19 years 17 males, 1 female. Two conditions:

  1. Teacher led in-class SBP. Fruit juice, milk, English muffins, blueberry muffins, bagels, cream cheese, eggs, toast, hot cakes

  2. No SBP

 In-class observation conducted by teacher in academic and vocational setting. Behavior coded: on-task. Increase in on-task behavior at follow up compared with baseline in both vocational and academic setting.
Low SES. Time sampling. Acceptable Inter-rater reliability in both settings. Decrease in subjective ratings of ability to stay on-task at follow up. High rate of off-task behavior at baseline.
Subjective ratings of ability to stay on task.
Benton et al. (2007) RM randomized acute experimental study. Primary school children (UK). n = 19, Mean age: 6 years, 10 months. Three conditions, 4-week SBP. Isocaloric BF at 0815–0845 h of differing GL

  1. High GL: Cornflakes, semi-skimmed milk, sugar, waffle, syrup (305 Kcal/39 GL)

  2. Medium GL: Scrambled egg, bread, jam, spread, yoghurt (284 Kcal/14.8 GL)

  3. Low GL: Ham, cheese, linseed bread, spread (299 Kcal/5.9 GL)

 Two observations.

  1. Video recorded in-class observation at 1030–1100 h (+135 min post BF) during independent quiet work. Time sampling. Behavior coded: on-task, looking around room, talking to peers, fidgeting, negatively interacting with peers, out of seat.

  2. Reaction to frustration measured by response to difficult video game. Behavior coded: concentrating, fidgeting, physical signs of frustration, negative verbal comments.

 Meal × time interaction for time on-task in first 10 min of class observation. Significantly more time spent on-task after consuming low GL BF compared with med GL BF and high GL BF. No significant effect of BF on other behavior. GL of BF negatively predicted performance on video game on first test occasion (behavior better after low GL BF).
Low SES school.
Cueto and Chinen (2008) SBP evaluation. 11 intervention schools, 9 control schools. Multiple and full grade schools. 3-year intervention. Primary schools (Peru) n = 590. Two conditions:

  1. Free Mid-morning SBP: BF during school break time at 1000–1100 h. Milk-like beverage and 6 biscuits (600 Kcal/60% RDA vitamins and minerals 100% RDA for Iron)

  2. Control: No BF/BF at home

 Behavior coded: Average time/day spent in classroom with teacher as proxy measure for on-task behavior. Reduction in time spent in classroom indicative of on-task behavior in intervention schools. Increased time spent in recess following SBP.
SBP: n = 300, mean age ± SD: 11.87 ± 1.77.
Male: 51.7%, Female: 48.3%
Control: n = 290 mean age ± SD: 11.87 ± 1.90.
Male: 49.7%, Female: 50.3%. 66–69% 1st grade children ≤2 SD height-for-age NCHS reference.
Wender and Solanto (1991) RM randomized acute experimental study. Double blind. Lab based (USA). n = 26. Controls: No ADD-H n = 9, mean age ± SD: 6.7 ± 0.7. ADD-H: n = 17, mean age ± SD: 6.9 ± 0.6. Two conditions. Isocaloric BF and drink (226 g) at 0900 h

  1. High sugar: Bread (1 slice), butter (5 g), and 35 g sugar drink (≈275 Kcals)

  2. Low sugar: Bread (2 slices) butter (15 g), and 0 g sugar drink sweetened 175 mg aspartame or saccharine. (≈275 Kcals)

 Video recorded playroom observation at 1000, 1100, 1200, 1300 h (+60, +120, +180 min post BF and +30 min post lunch). Behavior coded: Aggression, hitting, kicking throwing. Time sampling. Good periodic inter-rater reliability. No effects of BF on aggression.
Benton and Jarvis (2007) RM, randomized acute experimental study. Primary school children (UK). n = 20. Mean age: 9 years 4 months. Mid-morning snack, 1045 h after self-reported BF:

  1. Muesli bar 25 g (226 Kcal/35 g CHO)

  2. No snack

 In-class observation at 1115–1215 h (+30 min post mid-morning snack). Behavior coded: on-task, distracted, disruptive, interacting with teacher, out of chair. Categories collapsed into on-task or off-task behavior. Time sampling. Size of BF × snack interaction for on-task behavior. Children who consumed <150 Kcal BF spent significantly more time on-task when a snack was eaten. BF × snack interaction for off-task behavior. Children consuming <150 Kcal BF spent significantly more time off-task when no snack consumed compared with 151–230 Kcal and >230 Kcal BF. Children who consumed <150 Kcal BF spent significantly less time off-task when a snack was eaten.
Male: 50%, Female: 50%. Children classified depending on energy content of BF:

  1. <150 Kcal (Mean ± SE: 61.2 ± 18.5 Kcal)

  2. 151–230 Kcal (Mean ± SE: 209.7 ± 8.3 Kcal)

  3. >230 Kcal (Mean ± SE: 270.3 ± 64.8 Kcal)
Wahlstrom and Begalle (1999) SBP evaluation. 6 intervention schools. 3 control schools 3-year intervention. Primary schools (USA) n = 2901 children age 6–14 years. Proportion of children eligible for FSM or reduced priced meals: 20.4–77.3%. Two conditions:

  1. Intervention: Free SBP Unstandardized. Average daily participation rate: 68.9–97.5%

  2. Control: No SBP

 Interviews with teachers and questionnaires completed by teachers. Teachers perceived positive impact of SBP on social behavior and readiness to learn compared with pre intervention. Teacher reported increase attention and concentration following SBP. Decrease in discipline referrals following SBP.
Behavior assessed: Readiness to learn and social behavior. Number of discipline referrals.
Overby and Hoigaard (2012) Cross-sectional survey study. Four secondary schools (Norway). n = 475, mean age (SD) 14.6 ± 0.56, Male: 49.7%, Female: 50.3%. Questionnaire, 1 item to measure BF. BF intake classified as:

  1. Often: BF >5 days/week

  2. Never/seldom: BF ≤5 days/per week

 Self-reported behavior. 4-item questionnaire to measure disruptive behavior in class. Score range: 4–20. Higher scores indicating poorer behavior. Total scores dichotomized into two categories: No behavioral problems: 4–11 Behavioral problems: 12–20 Frequent breakfast consumption significantly associated with decreased odds of behavior problems (AOR: 0.29 95% CI: 0.15–0.55) compared with never/seldom consumption following adjustment for gender and BMI.
Murphy et al. (1998) SBP evaluation. Pre-post test. 4-month intervention. Three primary schools (USA) n = 133 mean age ± SD: 10.3 ± 1.6 years. Free SBP. Considered nutritionally balanced including milk, RTEC, bread, muffin, fruit, juice. Stratified by SBP participation:

  1. Often: ≥80% attendance

  2. Sometimes: 20–79% attendance

  3. Rarely: <20% attendance

 Conners Teacher Rating Scale hyperactivity index 10-item. Significantly greater decreases in hyperactivity scores in children who increased participation in SBP post intervention compared with children who had not changed SBP participation.
Male: 44%, Female: 56%. Proportion of children eligible for FSM or reduced priced meals: >70%.
Ni Mhurchu et al. (2013) Cluster RCT, stepped wedge (sequential roll-out of intervention over 1 year period). SBP evaluation. 14 primary schools. 1 year intervention. Primary schools (New Zealand) n = 424 children aged 5–13 years. Two conditions:

  1. Free SBP: School run. Non-standardized. School selected food: Low sugar RTEC, low-fat milk, bread, spreads (honey, jam, and margarine), chocolate flavored milk powder, and sugar

  2. Control: No SBP

 The Strength and Difficulties Questionnaire completed by teachers. 25 items related to five dimensions: hyperactivity/inattention, emotional symptoms, conduct problems, peer relationship problems, and pro-social behavior. PISA Student Engagement Questionnaire to measure self-report belonging and relationships with other students. No significant effect of SBP on behavior vs. control. Proportion of children eating BF everyday did not change. Decrease in proportion of children eating BF at home, increase in proportion of children eating BF at school.
Male: 47%, Female: 53%.
Low SES schools.
Murphy et al. (2011) Clustered RCT with a repeated cross-sectional design. 56 control schools, 55 intervention schools. SBP evaluation. 1 year intervention. Primary schools (UK). n = 4350 baseline, n = 4472 follow-up aged 9–11 years. Teacher completed behavior assessment on sub-sample of 5 pupils in 2 year groups. Control: n = 473 Intervention: n = 485. Two conditions:

  1. Intervention: SBP, Non- sugar coated RTEC, milk, bread, fruit. Considered nutritionally balanced

  2. Control: No SBP, wait listed control

 The Strength and Difficulties Questionnaire completed by teachers. Classroom behavior rated. Hyperactivity/inattention scale used as potential relationship with on-task behavior. No difference in classroom behavior in intervention vs. control schools.
Shemilt et al. (2004) Clustered RCT with observational analysis due to contamination between treatment arms. 3-month follow up (CT testing outcomes) and 1 year follow up (behavioral outcomes). Primary and secondary schools (UK) n = 6042 Control: n = 2369, mean age ± SD: 10.13 ± 3.93. Male: 52%, Female: 48%. Intervention: n = 3673, mean age ± SD: 9.59 ± 2.96 Male: 49%, Female: 51%. Two conditions:

  1. Funding for free SBP

  2. Control: No funding for SBP

 The Strength and Difficulties Questionnaire. Teachers completed questionnaire for primary school children. Self-report version for secondary school children. 25-item related to five dimensions: hyperactivity/inattention, emotional symptoms, conduct problems, peer relationship problems, and pro-social behavior. Score dichotomized into normal or borderline/abnormal for each dimension. Significantly higher proportion of primary school BF club attendees had borderline/abnormal conduct and total difficulties scores compared to non-attendees following adjustment for confounders. Significantly higher proportion of secondary school BF club attendees had borderline/abnormal pro-social scores compared with non-attendees following adjustment for confounders. Adjusted for school type, gender, FSM status.
For analysis of behavior, children classified as:

  1. Non-attendees: Never attended

  2. Attendees: Attended at least once

O'Sullivan et al. (2009) Cross-sectional survey study. The Western Australian Pregnancy cohort study. School children (Australia) n = 836, aged 13–15 years, Male: 50.7% Female: 49.3% Majority well-nourished, 5.7% underweight. Three-day food diary. BF intake classified based on 5 core food groups defined by AGHE: Bread and cereals, vegetables, fruit, dairy, and dairy alternatives, meat, and meat alternatives.

  1. No food or drink/water only

  2. Non nutritious food and drink

  3. Food from 1 AGHE core food group

  4. Food from 2 AGHE core food group

  5. Food from ≥3 AGHE core food group

 Child Behavior Checklist completed by parents (higher score indicates poor behavior), 118-item. Increase in BF quality associated with decrease in internalizing behavior score and a decrease in externalizing behavior scores. Increase in BF quality associated with decrease in total child behavior score. Stepwise decrease in total score with increasing breakfast quality. Adjusted for: PA, sedentary behavior, weight status, family income, maternal education, maternal age of conception, family structure, family functioning.
Internalizing behavior: Somatic complaints, withdrawal, anxious/depressed
Externalizing behavior: Aggression, delinquency Total behavior: Internalizing subscale, externalizing subscale, social thought, and attention problems.
Miller et al. (2012) Prospective cohort study. Part of ECLS-K national study. Data collection in five waves: 1999 (preschool), 2000 (grade 1), 2002 (grade 3), 2004 (grade 5), 2007 (grade 8). Preschool- primary school children (USA) n = 21400 at baseline, n = 9700 at final follow up, aged 5–15 years (mean 6.09 years) Male: 51%, Female: 49%. Parental questionnaire, 1 item to assess family BF frequency. BF classified as frequency/week (0–7) Internalizing and externalizing subscales of the Social Rating Scale adapted from Social Skills Rating System. No significant association between frequency of family BF and behavior. Fixed effects model results used as provides most unbiased estimates: account for all controls and eliminates between-subject variation. Extensive controls: Gender, ethnicity, family SES, parental education, family income, parental job prestige, family structure, area of residence, language, maternal employment during preschool, birth weight, teaching quality, school quality, region of residence, parental working hours, single parent family.
Externalizing subscale behavior coded: arguing, fighting, angry, impulsivity, disturbed activities, talked during quiet study.
Internalizing subscale behavior coded: anxious, lonely, sad, low self-esteem.
Teachers rated behavior until grade 5. Children completed scales at grade 8. Acceptable to good reliability on both scales.

ADD-H, attention deficit disorder-hyperactivity; AGHE, australian guide to health eating; BMI, body mass index; BF, breakfast; CHO, carbohydrate; CT, cognitive testing; ECLS-K, early childhood longitudinal study kindergarten cohort; FSM, free school meals; GI, glycaemic index; GL, glycaemic load; IG, independent groups; Kcal, kilocalorie; NCHS, national center for health statistics; PA, physical activity; PISA, programme for international student assessment; RCT, randomized control trial; RDA, recommended daily allowance; RM, repeated measures; RTEC, ready to eat cereal; SBP, school breakfast program; SD, standard deviation; SES, socio-economic status.