International Journal of Public Health Science (IJPHS)

Vol. 13, No. 1, March 2024, pp. 413~420

ISSN: 2252-8806, DOI: 10.11591/ijphs.v13i1.23521  413

Eating skills in children with autism via video modeling: an

evaluation of face and content validation

Nurul Khairani Ismail1, Hasrul Hosshan2, Nurbieta Abd Aziz2, Abdul Halim Masnan1,
Norsayyidatina Che Rozubi3, Mohd Muslim Md Zalli4
1
Department of Early Childhood Education, Faculty of Human Development, Sultan Idris Education University, Perak, Malaysia
2
Department of Special Education, Faculty of Human Development, Sultan Idris Education University, Perak, Malaysia
3
Department of Psychology and Counselling, Faculty of Human Development, Sultan Idris Education University, Perak, Malaysia
4
Department of Educational Studies, Faculty of Human Development, Sultan Idris Education University, Perak, Malaysia

Article Info ABSTRACT

Children with autism spectrum disorder (ASD) may have their eating habits
Article history: impacted by their traits, such as difficulty remaining seated at the table and
Received Jun 6, 2023 exhibiting behaviors during mealtime. This often worries parents and causes
stress and anxiety. Given video modeling's potential in helping children with
Revised Jul 18, 2023
ASD, experts should evaluate its effectiveness for teaching eating skills due
Accepted 27, 2023 to limited research in this area. Thus, the study aim to evaluate the validity of
the developed videos of eating skills for children with ASD. For face validity,
a focus group discussion was held to obtain experts' feedback on the eating
Keywords:
skills video and was transcribed verbatim. Otherwise for content validity, the
Children with autism experts received content validity assessment forms and guidelines via email
Content validation and the results was analysed using Microsoft excell. Face validity revealed
Eating skills four themes: suitability of videos, video quality and clarity, video instructions
suitability, task analysis arrangement, and "other" recommendations. On the
Face validation
other hand, Video 1 and Video 2 scored 0.93 for relevance, clarity, simplicity,
Video modeling and ambiguity for the S-CVI/Ave (scale-level content validity index based on
the average method) which was considered acceptable. Video 3 received a
satisfactory S-CVI/Ave score of 0.93 for relevance, simplicity, and ambiguity,
but its clarity score at 0.91, and still within an acceptable range, though not
particularly high. As a conclusion, all task analyses for the videos met the
requirement to be considered acceptable. Addressing the suggestions for
improvement can increase the video's efficacy in teaching eating skills and
relieving parents' concerns.
This is an open access article under the CC BY-SA license.

Corresponding Author:
Hasrul Hosshan
Department of Special Education, Faculty of Human Development, Sultan Idris Education University
35900 Tanjong Malim, Perak Darul Ridzuan, Malaysia
E-mail: [email protected]

1. INTRODUCTION
Autism spectrum disorder (ASD) is a neurological developmental disorder characterized by a lack of
social communication skills and non-normative behavior [1]. The estimated average prevalence of autism
spectrum disorders in Asia, Europe, and North America is 1% [2]. One common concern for parents with
children with ASD is eating behavior. Children with ASD have been observed to experience eating problems,
as reported by approximately 70% of parents of autistic children [3], [4]. The prevalence of eating problems is
higher for children with ASD than for typically developing children [5] and children with other developmental
disorders, such as attention-deficit/hyperactivity disorder [6] or other intellectual disabilities [7].

Journal homepage: http://ijphs.iaescore.com

414  ISSN: 2252-8806

Eating disorders may result from behavioral, cognitive, and environmental factors in children with
ASD [8]. Due to the changes in how children with ASD process information, mealtimes can be difficult for
them due to the sensory input from both food and their surroundings [9]. Prior research suggests that children
with ASD may also experience issues with staying seated at the table during mealtimes [5], [10], [11], gagging
[5], closing the mouth tightly during chewing [11], displaying aggressive or disruptive behaviors during
mealtime [7], [11] and pocketing food without swallowing [6]. Although children with ASD potentially
experience eating problems during their early childhood, these issues typically become resolved with agen [5],
[6], [7]. Nevertheless, it has been observed that certain behaviors tend to persist during childhood and
adolescence, like having food preferences or engaging in the consumption of particular foods [5].
Parents often express concern about eating problems among children with ASD, which represents a
source of anxiety and stress for parents [12]. Therefore, it is essential to understand better the issues
surrounding this eating problem to expand the evidence base that can be used to develop the most effective
intervention strategies for treatment [13]. Previous research has indicated that instructional methods that
include aids such, as pictures, in vivo modeling, and video modeling are recognized as evidence-based
approaches for children with ASD [14], [15]. The video modeling method is based on [16] social learning
theory, which asserts that observational learning through modeling profoundly influences children's skill
development. As a result of these strategies, individuals with ASD are far more able to process visual
information because they are more likely to engage with media support [17]. This strategy can eliminate visual
and auditory interfering stimuli and is not stressful for children with ASD [18], [19].
Furthermore, research reveals that children with ASD may be able to understand ideas and
circumstances more clearly through "social stories” because it can help children with ASD understand and
navigate social situations by providing clear descriptions, desired actions, and familiar social cues [20], [21].
There has been concrete evidence that video modeling, video self-modeling, or social story (or social story
combined with video modeling) can improve the social skills of individuals with ASD [22], [23], [24].
However, to date, research and data on video modeling and social stories in improving the eating skills of
children with ASD are still limited. Due to the nature of the research, the videos created for this study must be
evaluated for quality. Information about measurement instruments in the health field should be evaluated to
eliminate or modify unnecessary elements and add pertinent details to improve cohesion [25]. For this reason,
experts from the relevant expertise should conduct assessments before the module can be used to ensure the
accuracy of the intended measurement items [26], [27]. Therefore, the purpose of the study is to evaluate the
validity of the developed videos of eating skills for children with ASD.

2. METHOD
2.1. Research design and expert selection
The study used a methodology known as design and development research (DDR), which is justified
due to its pragmatic nature in testing theories and validating practicality that allows for establishing new
procedures, techniques, and tools based on a thorough analysis of specific needs. Before the study began,
ethical approval was granted from the Malaysia Social Welfare Department (JKMM 100/12/5/2:2022/492) and
the Research Management Innovation Centre (RMIC-2022-0527-01) at UPSI. During this phase of the study,
we sought feedback from 14 individuals who have expertise in fields such as special education, early childhood
education, educational technology, experienced teaching professionals, occupational therapists, and
rehabilitation center managers. Among the experts, there were eight university lecturers, three therapists, two
experienced teachers, and one rehabilitation center manager. We obtained both feedback regarding content
validity and qualitative feedback regarding face validity.

2.2. Video development, testing, and validity

The developed eating skills videos have three sections: introduction, content, and conclusion. In
developing the eating video, the research team conducted an extensive literature review to find suitable items,
and then the validity was evaluated by 14 experts. Face validity was used to measure whether the videos truly
represent their intentions. A semi-structured interview was used to improve clarity, understandability, and
congruence. Before the session, the experts were provided with the developed eating video. A focus group
discussion (FGD) was conducted after giving experts a certain period. The FGD aimed to get experts' feedback
on the developed eating skills video. In the workshop, the experts gave their input on the video, and the sessions
were recorded and transcribed verbatim.
Content validity assesses the representation of a concept by an instrument or module [28]. The content
validity index (CVI) of the video was determined by four elements, which are relevancy [29] and simplicity,
clarity, and ambiguity [30]. The four elements were rated using a 4-point Likert scale. The four elements were
marked as one for a total revision, two for major revisions, three for minor revisions, and four for good

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Int J Public Health Sci ISSN: 2252-8806  415

condition. The experts were given content validity assessment forms and guidelines on assessing the study's
content validity through e-mail. The videos were marked as Video 1 for spoon-eating, Video 2 for fork-eating,
and Video 3 for one-handed eating. Scores from the experts were compiled, and the videos were improved
based on the experts' suggestions. The data was measured from task analysis proportion, I-CVI as well as video
as a whole, and S-CVI [29].
Before calculating the CVI, the rating must be recorded as 1 (scale of 3 or 4) or 0 (scale of 1 or 2).
The I-CVI and S-CVI/Ave were calculated from expert scores. The I-CVI was obtained by dividing the scores
of the experts in agreement by the number of experts. The S-CVI/Ave was calculated based on the proportion
of items on the scale that received a relevance score of 3 or 4 from all experts. Acceptable levels for both
I-CVI and S-CVI/Ave were determined as a proportion of rater scores between 0.78 and 1.00, with 14 experts
involved [29].

3. RESULTS AND DISCUSSION

3.1. Face validity
According to the expert, the video can be improved by including simple activities for children with
ASD and avoiding complicated task analysis without extra sub-skills. The results of this face validity suggest
that the videos should be easy, suited to children's level of development, and enjoyable. The memory pattern
observed in children with ASD can be conceptualized within the framework of autism as a disorder of the
processing of information by the brain [31]. This child seems to struggle with remembering information,
whether it's a number of individual elements or a single complicated element, both in written and visual formats
[32]. Thus, the task analysis provided to the ASD child should be a single and straightforward task. This is
because, for children with ASD, whenever their cognitive load increases, it eventually will result in a decrease
in its effectiveness. Single tasks help children focus and avoid overstimulation. It also helps children break
down complex activities into simpler ones.
In addition, the experts also provided suggestions regarding safety concerns related to the handling of
materials. Improper handling of materials not only affects the clarity of the steps in the video but could also
affect the children's safety. Even though injury risks among children with ASD vary by age and demographics,
the injury risk among younger children with ASD has been observed as more significant than that among older
children with ASD [33]. Children with ASD are more likely to have alleged injuries due to common
development delays and motor impairments, with a 3-fold higher risk than their neurotypical peers [33], [34].
On the other hand, children with ASD do not know how to ask for help or self-advocate for themselves,
especially in dangerous situations. This is because they need more understanding of basic social
communication norms, and processing verbal information and instructions takes more time. Hence, safety
precautions should be considered in developing the video for this target population. Some additional
background music to the video can make it more engaging for the children and capture their attention, as well
as create an element of excitement. Numerous research studies have shown that children with ASD exhibit an
affinity for music. In fact, they have been observed to perform on par with their developing peers in this domain
[35], [36].
The second theme focused on video clarity, especially shooting angles. Children with ASD need
videos or authentic visuals at their eye level to understand what's coming next and reduce their anxiety. The
third concern revolves around the appropriateness of the instructions provided in the video. It is beneficial to
keep the instructions concise and straightforward. Using instructions with captions can help children better
comprehend the content of the video.
The video modeling is used with a social story to teach children eating skills in this module. Social
stories offer textual or visual cues and proper responses to assist ASD children in comprehending social
situations and becoming autonomous [37], [38]. However, lengthy instructions are discouraged, as this will
disrupt the children's learning process as they cannot locate and organize the various elements of the
information [39]. Based on Gray [38], it is recommended to have a balance of two to five sentences that
describe, provide perspective, and express affirmation for each directive sentence in a story. One of the
concerns raised by experts is ensuring that children remain engaged during the session by providing
reinforcement after completing task analysis. As mentioned in Bandura [16], video modeling relies on
attention, retention, motor reproduction, and reinforcement. In addition, Bandura [16] proposes that individuals
learn behavior through observation rather than solely responding to stimuli. In a live setting, the child can
watch the model directly or through a video of the model performing the targeted behavior to be imitated and
reproduced. According to Fryling et al. [40], children tend to imitate or avoid behaviors depending on the
negative outcomes they observe from others' actions. However, children with ASD may respond more to
tangible than abstract rewards (e.g., verbal praise). This may be because tangible rewards are more concrete
and immediate and thus may be more salient to children with ASD. Apart from that, they had some concerns

Eating skills in children with autism via video modeling: … (Nurul Khairani Ismail)
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related to the issues surrounding video production. These concerns include obtaining consent and addressing
them from the start of the process. It is also important to establish guidelines.
As known, ASD is complex, and there is no single way to approach teaching a child with ASD. Since
ASD encompasses many sub-categories, no two children will have the same symptoms. Although they may
behave similarly, they cannot be taught identically. Thus, individualized education manuals are necessary.
Therefore, the researcher must provide a manual that will enable the parent to assess the child's learning styles
and ensure that the learning environment is adapted and controlled methodically to ensure the child's successful
development.
In addition, the instructions should state that children with autism must already be able to imitate
before parents can show them the eating skill videos. Imitation has often been identified as one of the
fundamental skills necessary for video modeling [41]. Most children with ASD often struggle with imitation
skills. However, more information is needed about how these difficulties affect their performance in video
modeling [42], [43]. However, based on Bravo and Schwartz’s [44] study, children with ASD may perform
better on a task involving elicited imitation instead of spontaneous imitation when instructed when to do so.
The summary of the face validity result is shown in Table 1.

Table 1. Summary of face validity result

Themes Comment Recommendations
Suitability of Eating rice with chicken is difficult There is no need to add sub-skills for the existing skills. For
videos for example, eating chicken by hand, no need for rice with chicken.
activities The plate does not have complete nutrition Carbohydrates, protein, and fiber should be balanced on the plate.
Fried rice can replace chicken and rice.
Dull video Keep children engaged with background music in the video.
Inappropriate way of holding the materials Ensure children's safety by holding spoons and forks correctly.
Video quality The shooting angle is not appropriate. Ensure the model is in front of the camera to prevent the model's
and clarity excessive movement.
Suitability of Lengthy and wordy instruction The instructions should be short and precise, with a simple caption.
the instructions No introductory part on materials will be used Materials involved should be introduced first.
in the video Put picture assistance in the introductory segment.
Task analysis No rewards after completing a task analysis It should come with simple reinforcement (clapping, good job).
arrangement There is no final action after completing a task. A task analysis should be added; put the fork and spoon back on the
plate after eating.
Other No comment Ensure consent is obtained from the child's guardian.
Modules/videos should come with a personalized manual with clear
instructions.
Videos about pre-imitation skills should be included before eating
skills.

3.2. Content validity

The task analysis and qualitative feedback experts assigned scores of 5, 5 and 6 to each video in the
CVI form. They evaluated the videos based on criteria such as relevancy, clarity, simplicity, and ambiguity.
To meet the required standard of 0.78, all videos had to achieve an S-CVI/AVE score than or equal to this
threshold. The study's results indicated that one round of expert evaluations was necessary as shown in
Table 2 because all task analyses had an I-CVI and S-CVI/AVE score above 0.78. For video 1, spoon eating,
the I-CVI scores for relevancy, clarity, simplicity, and ambiguity were all at a level of 0.93. Similarly, video
2, fork eating, received I-CVI scores of 0.93 for relevancy, clarity, simplicity, and ambiguity. Regarding the
one-handed eating, it scored an I-CVI of 0.93 for relevance, simplicity, and ambiguity but scored slightly lower
at 0.86 for clarity (specifically steps 3 and 6). Both videos 1 and 2 achieved an S-CVI/AVE rating of 0.93
across relevancy, clarity, simplicity, and ambiguity. On the other hand, when it comes to video 3, one-handed
eating, the relevancy score was 0.93, clarity scored 0.91, simplicity scored 0.93, and ambiguity also scored 0.93.
Table 2 provides a summary of the scores given by 14 experts for I-CVI and S-CVI/AVE levels.
Content validity involves the extent to which the items chosen accurately represent the variables of
the construct being measured [45]. It can offer insights into the inclusiveness and comprehensibility of items,
aiding in the enhancement of a tool through the incorporation of suggestions from a panel of experts [46]. A
group of 14 experts participated in the study to offer their input on the task analysis of the created videos. As
cited by Escobar-Pérez and Cuervo-Martínez [47], a qualified expert has experience in the field, is regarded by
others as an expert, and can provide information, evidence, judgments, and assessments. This helps ensure that
the video is accurate and effective in teaching children with ASD how to develop appropriate eating skills. The
study included experts with content knowledge and experience related to the special needs of children with
ASD and experience managing such children. According to their assessment, the video was relevant, simple,
clear, and non-ambiguous. Almost all task analyses were considered appropriate and acceptable by at least 12

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experts. The video has met its intended purpose, implying its purpose has been achieved. Most items had
I-CVIs of 0.93, and the lowest I-CVI was 0.86 for only two items. Polit and Beck [46] advised that the CVI
achieves the minimal agreement of 0.78 for more than nine experts defined by Lynn [29] for outstanding
content validity.

Table 2. Summary of I-CVI and S-CVI/AVE scores

Task analysis Relevancy Clarity Simplicity Ambiguity
No. of expert I-CVI No. of expert I-CVI No. of expert I-CVI No. of expert I-CVI
agreement agreement agreement agreement
Video 1: Spoon eating
I grasp the spoon with one hand. 13 0.93 13 0.93 13 0.93 13 0.93
I took the food from the plate. 13 0.93 13 0.93 13 0.93 13 0.93
I brought the spoon and placed 13 0.93 13 0.93 13 0.93 13 0.93
the food into my mouth.
I chewed and swallowed the 13 0.93 13 0.93 13 0.93 13 0.93
food.
I repeat the same steps until the 13 0.93 13 0.93 13 0.93 13 0.93
food runs out
S-CVI/AVE 0.93 0.93 0.93 0.93
Video 2: Fork eating
I handled a fork with one hand 13 0.93 13 0.93 13 0.93 13 0.93
I pressed the fork's tips into the 13 0.93 13 0.93 13 0.93 13 0.93
food.
I brought the fork and put the 13 0.93 13 0.93 13 0.93 13 0.93
food into my mouth
I chewed and swallowed the 13 0.93 13 0.93 13 0.93 13 0.93
food.
I repeat the same steps until the 13 0.93 13 0.93 13 0.93 13 0.93
food runs out
S-CVI/AVE 0.93 0.93 0.93 0.93
Video 3: One-handed eating
I checked that my right hand was 13 0.93 13 0.93 13 0.93 13 0.93
clean.
I pinched a small portion of 13 0.93 13 0.93 13 0.93 13 0.93
chicken
I mix chicken with rice 13 0.93 13 0.86 13 0.86 13 0.93
I took some rice with my fingers 13 0.93 13 0.93 13 0.93 13 0.93
I bring some rice into my mouth 13 0.93 13 0.93 12 0.93 13 0.93
I chewed and swallowed the rice. 13 0.93 12 0.86 13 0.86 13 0.93
I repeat the same steps until the 13 0.93 13 0.93 13 0.93 13 0.93
rice runs out
S-CVI/AVE 0.93 0.91 0.91 0.93

S-CVI/AVE for one-handed, spoon, and fork eating also exceeded 0.78 for relevancy, clarity,
simplicity, and ambiguity. The result indicates that the video has fulfilled the requirement. Results also suggest
no need for more than one round of expert reviews. For video 3, one-handed eating, the results of S-CVI/AVE
for clarity were slightly lower than others. It is explained that although the definition of the items was deemed
clear and straightforward, slight confusion still needed to be noted. Both task analyses were kept in the video,
and changes were made based on expert feedback, either on content or technical issues. Thus, according to the
findings of this study, the items are relevant, clear, simple, and have no ambiguity.

4. CONCLUSION
Using video modeling with social stories is considered a practice that is supported by evidence and
takes advantage of the strengths of children with ASD. However, it is important to evaluate the videos to ensure
their validity. This study met the requirement to be considered acceptable as task analyses or for the videos
themselves for all three videos through content validity evaluation and some positive feedback form experts
regarding face validity. By taking into consideration on recommendations for enhancement can enhance the
effectiveness of the video in teaching eating skills and alleviating parental anxieties.
.
ACKNOWLEDGEMENTS
The research team expresses gratitude towards Sultan Idris Education University (UPSI) for funding
this research project under the Special Interest Group Grant (SIG Research Code: 2021-0132-107- 01).

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BIOGRAPHIES OF AUTHORS

Nurul Khairani Ismail is a Post Doctoral officer at University Pendidikan

Sultan Idris, Tanjung Malim Perak. Her educational background includes a Bachelor's degree
in Nursing from International Islamic University Malaysia's Kuantan campus, a second
degree in education, specializing in Educational Psychology from the same university, and a
Ph.D. in Preschool Education from Universiti Kebangsaan Malaysia. She has experience in
teaching and as researcher at UKM and USM, as well as a research fellow at the Malaysia
Institute of Road Safety Research (MIROS). Her research interests and experience are varied,
ranging from early childhood and special education through character education and road
safety training for youngsters. She can be contacted at email: [email protected].

Hasrul Hosshan is a Senior Lecturer at the Faculty of Human Development,

Universiti Pendidikan Sultan Idris (UPSI), Malaysia and Honorary Lecturer at, Centre on
Disability Research and Policy, The University of Sydney, Australia. He does research in
education and community setting specifically related to disability inclusion, social
participation, center based-rehabilitation, parenting and teaching quality. He is also a member
of the International Association for the Scientific Study of Intellectual and Developmental
Disabilities (IASSIDD). He is actively involved as a Disability Advocacy in local and
international level. He can be contacted at email: [email protected].

Eating skills in children with autism via video modeling: … (Nurul Khairani Ismail)
420  ISSN: 2252-8806

Nurbieta Abd Aziz received her PhD in Occupational Therapy from Universiti
Kebangsaan Malaysia (2022), MSc in Disability Policy and Practice from Flinders University
Australia (2016), Bachelor (Hons) in Occupational Therapy from Universiti Kebangsaan
Malaysia (2009) and Diploma in Occupational Therapy from Universiti Teknologi Mara
(2001). She has 22 years of experience in Occupational Therapy fields. She is a senior lecturer
at the Department of Special Education, Faculty of Human Development, Universiti
Pendidikan Sultan Idris. Her expertise in Occupational Therapy interventions for children
with special needs, including autism spectrum disorders. She can be contacted at email:
[email protected].

Abdul Halim Masnan is the Assoc. Prof of Department of Early Childhood

Education at Universiti Pendidikan Sultan Idris. He is a PhD holder from the Universiti Sains
Malaysia. He is an Adjunct Professor at UNITAR and a visiting professor at UNNES,
Semarang, Indonesia. He also received an Erasmus grant in March 2022 for a 3-week
teaching mobility program at Trnava University, Slovakia. He specializes in Early Childhood
Education. His expertise in Pedagogy in Early Childhood Education made him a team
member conducting research projects and advisory boards in Malaysia and overseas. He can
be contacted at email: [email protected].

Norsayyidatina Che Rozubi is a Senior Lecturer in Counselling at the

Psychology and Counselling Department, Faculty of Human Development, Sultan Idris
Education University (UPSI) and is a registered counsellor. She graduated with a B. ed
(Counselling and Guidance) from University Malaya (UM) in 2008. She later completed her
M. Ed (Counselling and Guidance) at National University Malaysia (UKM) in 2011 and Phd
in Counselling at University Malaya in 2017. She has 15 years of experience in counselling
and had served as a counsellor in boarding school. Her expertise is in children's counselling.
Now she is doing postdoctoral at University of Edinburgh, United Kingdom, focusing on
child sexual abuse and exploitation. She can be contacted at email:
[email protected].

Mohd Muslim Md Zalli is a Senior Lecturer at the Faculty of Human

Development, Universiti Pendidikan Sultan Idris (UPSI), Malaysia. He does research in
higher learning education and school setting specifically related to learners' behavior in online
courses, learning strategies, and teaching quality. He is also a member of the International
Study Association on Teachers and Teaching and is actively involved as the ATLAS.ti
certified trainer. He can be contacted at email: [email protected]

Int J Public Health Sci, Vol. 13, No. 1, March 2024: 413-420