Appetite 120 (2018) 609e615

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Appetite
journal homepage: www.elsevier.com/locate/appet

Evaluation of a pilot sensory play intervention to increase fruit

acceptance in preschool children
H. Coulthard*, I. Williamson, Z. Palfreyman, S. Lyttle
Division of Psychology, Faculty of Health & Life Sciences, Hawthorn Building, De Montfort University, Leicester, LE1 9BH, United Kingdom

a r t i c l e i n f o a b s t r a c t

Article history: Recent research has found an association between dislike of messy play and higher levels of food neo-
Received 22 September 2016 phobia in children. The aim of the present study was to pilot and assess a five week intervention with
Received in revised form preschool children, to examine whether engagement in tactile sensory tasks leads to increased fruit
14 July 2017
acceptance. Interventions were carried out to examine whether weekly sessions of sensory play com-
Accepted 6 October 2017
bined with fruit exposure, would increase acceptance and enjoyment of fruits to a greater extent than
Available online 7 October 2017
two non-sensory play conditions featuring fruit exposure or normal play activities alone. One hundred
children aged 18 months to four years were recruited from ten playgroups in the Midlands area of the
Keywords:
Fruit consumption
United Kingdom (UK) of which 83 completed the interventions. Participants were randomly assigned to
Neophobia one of four conditions: combined sensory play (fruit and non-food), non-food sensory play, fruit taste
Child exposure, and control play. There were baseline differences in child fruit acceptance, so this was entered
Intervention as a covariate into subsequent analyses. It was found that children in both the combined sensory play and
Sensory processing non-food sensory play conditions enjoyed significantly more fruits at follow up than children in the
Healthy eating control play condition, whilst children in the non-food sensory play group also enjoyed significantly
more fruits than the fruit exposure group. These findings suggest that sensory play, with fruit and/or
non-food substances, combined with exposure may be an effective strategy to increase tasting and fruit
acceptance in children.
© 2017 Published by Elsevier Ltd.

1. Introduction individual differences in food rejection behaviours such as food

Naturally occurring foods such as fruits and vegetables are
known to have health benefits (e.g. Dauchet, Amouyel, Hercberg, &
Dallongeville, 2006), but are amongst the most rejected and dis-
liked food groups. In particular children after the age of two are
particularly resistant to tasting and accepting novel fruits and
vegetables, as part of the expression of the neophobic food
response, and will often reject these foods on sight (Cooke, Wardle,
& Gibson, 2003; Howard, Mallan, Byrne, Magarey & Daniels, 2012;
Pliner, 1994). Recently there has been an increased interest in the
contribution of sensory processing to the hedonic experience of
eating and hence the acceptance of foods. Eating is an intensely
multi-sensory experience; we see food, smell it and even touch it
with our hands before deciding to taste it. It is becoming increasing
apparent that the hedonic sensory experience of eating a given food
differs between individuals, and may to some extent explain
* Corresponding author.
E-mail address: hcoulthard@dmu.ac.uk (H. Coulthard).
neophobia.
It is acknowledged that individuals vary in the extent to which
they perceive and respond to sensory stimuli in the environment,
such as the feeling of sand or the smell of perfume (Dunn, 1997).
Eating involves sensory integration across a range of sensory mo-
dalities; not only the obvious modalities of olfaction and taste, but
also the visual appearance of food and the feel of food in the mouth.
In both behavioural (Coulthard & Thaker, 2015; Coulthard & Sahota,
2016; Nederkorn, Jansen & Havermans, 2015); and questionnaire
studies (Coulthard & Blissett, 2009), it has been found that tactile
processing, which relates to evaluation of the feel of different
substances (both food and non-food) may be associated with the
acceptance of foods. This in some ways is not surprising, as the
texture of a food is processed within the mouth. More specifically, it
is also found that the texture of a given food is a major determinant
of liking and acceptability (Werthmann et al., 2015; Zeinstra,
Koelen, Kok, & de Graaf, 2010). The mouth is said to be the final
sentry post through which substances pass from the external world
to the internal body, and it is important for survival to judge

https://doi.org/10.1016/j.appet.2017.10.011
0195-6663/© 2017 Published by Elsevier Ltd.
610 H. Coulthard et al. / Appetite 120 (2018) 609e615
whether foods are safe prior to ingestion (Rozin, Haidt, & McCauley,
2008). The texture of some foods change as they become unsafe to
eat, for example they may become slimy and mushy as they rot. It is
therefore likely that texture evaluation may be an important aspect
of food acceptance and rejection, with slimy textures being the
most disliked (Martins & Pliner, 2006).
One of the most effective strategies for increasing acceptance of
foods in infants and children is to increase familiarity with their
taste through the technique of taste exposure (Ahern, Caton,
Blundell & Hetherington, 2014; Holley, Haycraft, & Farrow, 2015;
Horne et al., 2011). However, taste exposure becomes increasingly
less effective after the age of two years as more exposures are
required to increase preference (Howard et al. 2012; Sullivan &
Birch, 1990) and food rejection increasingly occurs on sight rather
than taste (Birch, McPhee, Shoba, Pirok, & Steinberg, 1987; Dovey
et al., 2012). Interventions in preschool children have traditionally
encompassed taste exposure alongside other proven strategies
such as modelling (copying others) and rewards (Holley et al., 2015;
Horne et al., 2011; Laureati, Bergamaschi, & Pagliarini, 2014).
Generally these interventions have been found to be effective
compared to control groups, but have tended not to look at indi-
vidual child differences in outcomes. In addition, the rewards
associated with these interventions tend to be costly, and some-
times the interventions themselves are expensive when translated
into a school environment and are not self-sustaining.
There has been a very recent shift in using games to increase
novel food consumption, as they are low cost, fun and intrinsically
rewarding. For older children, research has examined games which
encompass collaborative FV consumption targets in the canteen,
with each target releasing a different stage of a story about
‘catching villains and saving heroes’ (Jones, Madden, & Wengreen,
2014) or playing ‘bingo’ with real fruits and vegetables (Coulthard &
Ahmed, 2017). Games with younger children have encompassed
sensory play with food and non-food substances, for example
making pictures with FV (Coulthard & Sealy, 2017) and afterwards
tasting the featured foods. Sensory play with foods allows multi-
sensory exploration and exposure to the appearance, smell, and feel
of foods without pressure to taste. This method means that con-
sumption is not the end activity of the task, rather that the food is
used as a play substance (Coulthard & Ahmed, 2017; Coulthard &
Sealy, 2017).
There have been several research studies which have examined
whether sensory education tasks with foods can desensitise chil-
dren to the novel aspects of their sensory properties, and make
these foods more familiar and consequently accepted. In older
children tasks have centred on education of the senses through
‘classes de gout’, where 8e11 year old children are trained to
identify the different sensory properties of foods through their
smell and taste. In younger children, interventions have ranged
from sensory education across the senses, for example, opening up
fruits to look at their seeds (Dazeley & Houston-Price, 2015; Hoppu,
Prinz, Ojansivu, Laaksonen, & Sandell, 2015) to imaginative games
with a fruit and vegetable theme (Witt & Dunn, 2012). However, as
yet, there have been no intervention studies which have used game
based activities where the food itself is the play stimuli.
The aim of the present study was to construct an intervention
based on sensory play, and examine whether this would be asso-
ciated with increased fruit consumption in preschool children. The
decision to focus on fruits rather than FV was taken, as there is a
move to view these as separate food groups (e.g. Dovey et al., 2012).
For the purposes of this intervention, we selected food stimuli that
would leave a trace on the body, and could also be consumed raw.
Therefore it was decided to use fruit stimuli, as these offered a
more flexible range of foods to choose from. It was hypothesised
that taking part in a five week sensory play intervention combined
with taste exposure would be associated with subsequent
increased fruit acceptance, compared to groups who were given
either taste exposure or non-food play activities over the five week
period. There were two sensory play interventions, one with fruit
and non-food sensory games and a second group that only took
part in non-food sensory games. The rationale for these two
different sensory play conditions was to examine whether playing
with fruit would lead to greater tasting than multisensory exposure
through messy play (Coulthard & Sealy, 2017). A secondary aim was
to examine whether there were differences in enjoyment of the
different games, in particular whether children disliked the feel of
more ‘slimy’ fruit and non-food substances compared to other
textures.
2. Method
2.1. Participants
One hundred children and an accompanying parent were
recruited from preschool playgroups (n ¼ 10) in the East and West
Midlands of the United Kingdom (UK). They were invited to take
part in a study on fruit consumption in preschool children, so that
they were blind to the different experimental conditions. Children
with known allergies to foods were excluded from the study. As
lychee was used to test willingness to try an unfamiliar fruit at the
end of the study, previous consumption of lychee was used an
exclusion criterion. The initial sample comprised 48 boys and 52
girls, with a mean age of 2.60 (SD ¼ 0.81) years. The majority of the
sample was White British (82%, n ¼ 68), with the remainder of the
sample from White European (7%, n ¼ 6), South Asian (5%, n ¼ 4)
and Mixed Heritage (6%, n ¼ 5) backgrounds. Seventeen partici-
pants were not included as they failed to complete the baseline
measures (n ¼ 2) or complete the five week intervention or final
session (n ¼ 15). As this was a voluntary play group and we didn't
have contact details for the caregivers, we were unable to collect
reasons for drop-out. Eighty-three children completed the 5 week
intervention study, and a follow up session to examine fruit
acceptance, and were included in the final analyses. The final
sample had 38 boys and 45 girls, with a mean age of 2.75 (0.82)
years. Each playgroup was assigned to one experimental condition,
so caregivers were not aware of the different conditions until after
the follow up tasting measure was carried out, to prevent demand
characteristics.
2.2. Design
A between participants’ experimental design, with cluster ran-
domisation was carried out. Each playgroup was randomly assigned
to one experimental group using number generation. There was
one factor with four levels; the experimental group to which each
child was assigned (Combined sensory play with exposure, non-
food sensory play with exposure, taste exposure and control
play). For each condition, twenty-five children were recruited.
Caregivers were asked to provide information on a range of factors
designed to help describe and understand the sample and to assess
any baseline differences so these could be controlled for in subse-
quent analyses. These possible covariates included parental edu-
cation, age of child, age of parent, child food neophobia, range of
fruits accepted, child FV consumption, parental FV consumption.
2.3. Materials and procedure
Child Food Neophobia Scale (CFNS). To measure the relation-
ship between the child's willingness to try new foods and their
acceptance of FV six of the ten items from the CFNS were used,
 H. Coulthard et al. / Appetite 120 (2018) 609e615
originally developed by Pliner and Hobden (1992). This shortened
form is considered to be more suitable for use with young children
(below 6 years) and has high Cronbach alpha scores (a ¼ 0.84;
Wardle, Carnell, & Cooke, 2005). The CFNS has been validated
against behavioural measures of child neophobia (Pliner, 1994). An
example of an item is', ‘My child is afraid to eat things s/he has never
had before’. All items are scored on a 4-point scale from strongly
agree to strongly disagree, with a high score indicating greater child
food neophobia.
Portions of Fruit and Vegetables (parent and child). To mea-
sure the typical portions of FV consumed by the child and parent in
a typical week, the parent completed a Likert scale for both
themselves and their child. This format has commonly been used in
similar research (Wardle et al., 2005), has been validated against 4-
day diaries (Bingham, Gill, Welch et al., 1994) and is a direct
replication of that used by Coulthard and Blissett (2009). In the
child version, the parent was asked to rate how often, in a typical
day, their child ate a portion of a) fruit and b) vegetable. The
questions were comprised of the statement ‘How often does your
child eat …’ followed by the food-group (1) vegetables (not potatoes),
(2) fruit. The definition of a portion was clearly defined in the in-
structions in accordance with UK government guidelines
(Department of Health, 2012), and was explained to the parent as
the amount that can be held in the hand of the individual in
question. Parents were asked to report the amount the child ate, so
that if they typically only ate half a portion offered they wrote down
half a portion, not one portion. They then filled in a similar scale for
their own consumption. The sum of (1) fruit and (2) vegetable
consumption were also totalled together to give a daily FV con-
sumption score.
Fruits Accepted. To assess the amount and variety of fruits
previously tried and accepted by the child we asked parents to
complete a checklist of 34 fruits commonly found in UK shops and
supermarkets. This checklist has been used in a similar study
(Coulthard & Blissett, 2009). For each fruit listed the parent is
required to mark whether their child has tried the fruit by marking
either ‘likes’, ‘dislikes’ ‘never tried’ or ‘don't know’. In the current
study we used the range of fruits liked as a single fruit acceptance
score, which was calculated by totalling the number of ‘like’ re-
sponses (0e34, with higher scores indicating a greater number of
fruits liked).
Tactile Sensitivity. To measure the relationship between the
child's tactile processing and their relationship to fruit consump-
tion we assessed tactile sensitivity through the tactile processing
subscale of The Sensory Profile (SP; Dunn, 1999). The Tactile pro-
cessing subscale of the SP has good reports of internal consistency
(Dunn, 1999) and high discriminate validity (>95%) of dis-
tinguishing children with and without problems with sensory
modulation (McIntosh, Miller, & Shyu, 1999). We used the toddler
version of the SP, which is suitable for use from 18 to 36 months
(Dunn & Daniels, 2002). Of the 15 items in the tactile processing
subscale, we selected 10 pertaining to the tactile sensitivity (low
threshold to touch). An example item is: My child avoids getting his/
her face wiped. Each item was scored on a five point scale; Almost
always (5), Frequently (4), Occasionally (3), Seldom (2), Almost
never (1). Scores ranged from 10 to 50, with a high score being
indicative of high tactile sensitivity.
Non-food sensory play tasks. There were five different non-
food sensory play tasks, one of each was carried out each week
with two of the experimental groups (combined sensory play and
non-food sensory play). Each task had a play narrative, and the
texture of the substances varied each week (bubble mixture, flour/
babyoil mixture, sand, goo, cornflour/water mixture). An example
of a task was the buried treasure game. A bowl (20 cm  20 cm) was
filled with play sand, and play coins were hidden underneath the
611
sand. The child sat at the table in front of the bowl with their
parent, and the researcher said “There is some treasure buried in the
sand. Can you find the buried treasure by digging it out?” For each
child the researcher and the parent evaluated the child's enjoyment
of the ‘feel of the game’ using a five point scale from strongly agree
(5) to strongly disagree (1), with a higher score indicating higher
enjoyment of the feel of the game. Inter-rater reliability of the
evaluation of liking the non-food sensory games between the
parent and researcher was evaluated using mean interclass corre-
lation (ICC) analysis. The levels of absolute agreement ranged from
0.75 to 0.92 between the two scorers, which was above acceptable
levels of (ICC ¼ 0.6), therefore a mean score for enjoyment of each
non-food sensory play task was calculated, ranging from 1 to 5 with
a higher score indicating higher enjoyment of the task.
Fruit sensory play tasks. Children allocated to the combined
sensory play condition also participated in five different fruit
sensory play tasks, with one of each being carried out each week
based on a single fruit (blueberries, prunes, raspberries, passion
fruit, melon). The rationale for choosing these fruits was to ensure
a range of colour, texture and shape, to ensure a wide variety of
sensory experience and possible games. Each task had a narrative
which focussed on the eventual aim of getting the child to put the
food on their skin. The fruit was presented in a small bowl on the
play table, and the child sat in front of the bowl with his/her
mother. An example of a narrative was, “We are going to play the
ladybird game today, where we turn into ladybirds by putting
spots on ourselves. Can you get some spots and put them on you”
(points to a bowl of blueberries). For each play task the researcher
and the parent rated the child's enjoyment of the task on a five
point scale from strongly agree to strongly disagree with a high
score indicating higher enjoyment of the game. Inter-rater reli-
ability of the evaluation of enjoyment of the fruit play tasks be-
tween the parent and researcher was evaluated using mean
interclass correlation (ICC) analysis. The levels of absolute agree-
ment ranged from 0.60 to 0.74 between the two scorers, which
was above acceptable levels of (ICC ¼ 0.6), therefore a mean score
for enjoyment of each of the fruit play tasks was calculated,
ranging from 1 to 5 with a higher score indicating higher enjoy-
ment of the fruit play task.
Fruit taste exposure. On each of the five weeks, the children in
the two sensory play conditions and the exposure group were given
a small piece of fruit to taste. The fruit was always the same as that
used in the fruit sensory play task that week (blueberry, prune,
raspberry, passion fruit, melon). The fruit tasting always occurred
after the sensory play tasks had finished. These fruits had been
prepared prior to the testing occasion in a food preparation envi-
ronment. Each child was given a small piece of the fruit (approxi-
mately 2 cm in size) on a white paper plate, and the researcher said
‘I would like you try a piece of this’. If the child was reluctant, they
were prompted twice. Both the parent and researcher rated how
much the child appeared to enjoy the fruit on a five point scale from
strongly agree (5) to strongly disagree (1), with a higher score
indicating higher enjoyment of the fruit. Children were given a
score of 0 if they refused to taste the fruit. Inter-rater reliability of
the evaluation of liking the fruits between the parent and
researcher was evaluated using mean interclass correlation (ICC)
analysis. The levels of absolute agreement ranged from 0.89 to 0.95
between the two scorers, which was above acceptable levels of
(ICC ¼ 0.6), therefore a mean score for enjoyment of each of the
fruits was calculated, ranging from 1 to 5 with a higher score
indicating higher enjoyment of the fruit.
Control play condition. In the control group, for the duration of
the five week intervention, the researcher came and played a game
with the child each week which did not encompass messy play or
exposure to fruits. Control group games included a shape sorting
612 H. Coulthard et al. / Appetite 120 (2018) 609e615
game, a ring game, a jigsaw puzzle and block building game. The
main aim of these games was to control for familiarisation with the
researcher, and these games were not rated for enjoyment by the
researcher and the parent.
Week 6 follow up taste test (fruit liked). In week 6 all children
were given a fruit taste test. They were presented with three fruits,
one universally familiar fruit (banana), one fruit that had been used
in the interventions (raspberry) and one fruit that was confirmed to
be novel to all the children (fresh lychee). Each of the fruits was
rated for baseline liking by the parent and how much the child
enjoyed it on the taste testing occasion by both the researcher and
the parent. The presentation and rating procedure was exactly the
same as for the exposure tasks which had been carried out every
week (see fruit taste exposure). Inter-rater reliability of the evalua-
tion of liking the fruits between the parent and researcher was
evaluated using mean interclass correlation (ICC) analysis. The
levels of absolute agreement ranged from 0.72 to 0.80 between the
two scorers, which was above acceptable levels of (ICC ¼ 0.6).
Therefore a mean score for enjoyment of each of the fruits was
calculated, ranging from 1 to 5 with a higher score indicating higher
enjoyment of the fruit. For each of the fruits a ‘difference in
acceptance score’ was calculated where the parent rating for how
much the food was normally liked (1e5 point scale, or 0 for never
tried before) was subtracted from mean score for how much they
enjoyed it on week 6 testing occasion (1e5 point scale, or 0 for
refusal to taste). The final score for each of the foods indicated how
much more they liked the fruit than they normally did on a scale
from þ5 to 5, with a high score indicating a higher change in
enjoyment. In addition, a total score for the sum of the three dif-
ference in acceptance scores, the ‘final fruit liked’ score, was
calculated which ranged from þ15 to 15, with a higher score
indicating a greater change in preference for the fruits.
Data analysis. All statistical tests were carried out on IBM SPSS
statistical software version 22 (IBM, 2013). Statistical significance
was set at p0.05 unless otherwise stated. Kolmogorov-Smirnov
tests for normality and inspection of stem and leaf plots indicated
that the majority of variables were normally distributed conse-
quently parametric tests were carried out on the data. One way
unrelated analyses of variance were carried out to examine de-
mographic and baseline differences in age (child and parent), daily
FV consumption (portions; child and parent), child tactile sensi-
tivity, child food neophobia and range of fruits accepted (child),
between the four experimental groups (Table 1). It was found that
there were differences in the range of fruits children accepted at
baseline and the age of the child, so these were entered as cova-
riates in subsequent analyses. One way analyses of covariance
(ANCOVA) were carried out to examine differences in tasting and
enjoying fruits at week 6 between the four experimental groups,
after controlling for fruit acceptance (child) and age (child). Custom
interaction models were carried out and it was found that the as-
sumptions of linearity were met p > 0.05 in both interactions.
Levene's test indicated that homogeneity of variance could be
assumed for all analyses (p > 0.05).
Pearson product-moment correlations were carried out to
examine associations between rated enjoyment of the fruit games,
non-food messy play games and liking the fruit at each of the five
intervention weeks.
Finally, one way related analyses of variance (ANOVA) were
carried out with Bonferroni post hoc tests, to examine differences
in enjoyment of the five fruit sensory play tasks and between the
five non-food sensory play tasks. In analyses where Mauchley's test
indicated that sphericity had been violated (p < 0.05), a Greenhouse
Geiser correction was applied.
3. Results
3.1. Baseline characteristics across the four experimental groups
Table 1 shows the differences in the baseline characteristics of
the child participants and their parents between the four condi-
tions. It was found that there were two baseline differences be-
tween the four experimental groups. Firstly there were differences
in child age across the sample, F(3, 81) ¼ 4.62, p < 0.05, h2p ¼ 0.13,
which indicated a large effect size. Bonferroni post hoc tests
showed that the fruit exposure group and the combined sensory
play group were younger than the non-food sensory play and the
play control group. There were also differences in range of fruits
accepted (child), F(3, 81) ¼ 4.67, p < 0.01, h2p ¼ 0.16, which indicated
a large effect size. Bonferroni post hoc tests showed that children in
the combined sensory play group had a lower baseline liking of
fruits than those in the non-food sensory play condition (p < 0.05),
the exposure condition (p < 0.05) and the control condition
(p < 0.05).
3.2. Differences in fruit enjoyment post intervention between the
four experimental groups
One way analyses of covariance were carried out to examine
whether there were differences in fruit enjoyment post-
intervention, after controlling for the covariates of baseline fruits
accepted (Child). There were differences in post-intervention total
fruit enjoyment across the four experimental groups, F(3,
82) ¼ 5.46, p < 0.05, h2p ¼ 0.18 which indicated a large effect size
(see Table 2). It was found that children in the non-food sensory
play condition enjoyed more fruits at follow up than children in the
taste exposure or control condition. In addition, children in the
combined sensory play condition enjoyed more fruits at follow up
than children in the control condition. There were differences in
lychee enjoyment post-intervention across the four experimental
groups, F(3, 82) ¼ 3.47, p < 0.05, h2p ¼ 0.12 which indicated a
moderate effect size. In particular, children in the non-food sensory
play condition enjoyed lychee more than children in the exposure
or control conditions (p < 0.05). Although there were no differences
in enjoyment of the novel fruit, Lychee, between the combined play
condition and the other conditions, there was a trend for children in
the combined play condition to enjoy lychee more than those in the
taste exposure condition (p < 0.10). There were also differences in
raspberry liked at week 6, in particular raspberry was more liked in
both the sensory play conditions compared to the control group
(p < 0.05). In addition banana at week 6 was liked more by children
in the non-food sensory play group compared to control group
children (p < 0.05).
3.3. Relationships between sensory play tasks and fruit enjoyment
Pearson product moment correlations were carried out to
examine relationships between enjoyment of play tasks and
enjoyment of the exposure fruit across the five week intervention
period. It was found that enjoyment of the exposure fruit was
associated with enjoyment of playing a game with the fruit (n ¼ 21)
and also playing a game with a non-food substance (n ¼ 41) (see
Table 3).
3.4. Differences in enjoyment of the sensory play tasks
Generally children in the combined sensory play condition, who
took part in both fruit and non-food play tasks (n ¼ 21), were rated
as enjoying the non-food play tasks more than the fruit play tasks,
t(20) ¼ 6.47, p < 0.001. There were differences in enjoyment of the
 H. Coulthard et al. / Appetite 120 (2018) 609e615 613

Table 1
Differences in baseline variables across the four conditions (sensory combined play, sensory non-food play, taste exposure and control) in a sample of 1e4 year old children
(N ¼ 83).

Combined Sensory play Nonfood sensory play Taste exposure Control Total
þ taste exposure þ taste exposure (n ¼ 21) (n ¼ 21)
(n ¼ 21) (n ¼ 20)

Child age (years) 2.18(0.65) 2.96(0.83) 2.56(0.84) 2.75(0.71)* 2.75 (0.82)

Child Sex (Male, female) 6, 15 10, 10 10, 11 13, 8 39, 44
Parental age (years) 33.17 (7.64) 31.04(8.50) 36.19(4.53) 35.62 (4.53) 33.97 (7.11)
Parental education (years)a 13.81(4.72) 16.68(3.73) 16.45(2.98) 17.00(1.86) 16.06(3.58)
Parental FV (portion/day)b 2.88(1.69) 4.00(2.49) 3.93(1.75) 4.28(1.64) 3.72(1.99)
Child FV (portion/day)b 3.36(2.35) 4.48(2.09) 4.20(2.27) 4.12(1.31) 4.03(2.09)
Tactile sensitivity 15.16(3.64) 15.58(4.10) 14.31(3.47) 13.46(2.53) 14.73(3.55)
Child food neophobia 15.00(3.70) 12.40(3.55) 12.88(2.40) 13.00(4.44) 13.36(3.71)
Fruit accepted (sum) 10.22(4.10) 15.12(5.54) 15.44(5.91) 15.80(5.67)** 14.022

p < 0.05*, p < 0.001**.

a
This was defined as the period of time spent in education since the age of 4 years on entry to school. 16 years in education refers to degree level education.
b
A portion was defined as the amount of fruit or vegetable that can be held in the hand of the individual. Potatoes were not considered as a vegetable.

Table 2
Differences in fruit tasting post intervention between the four conditions (sensory combined play, sensory non-food play, taste exposure and control) in a sample of 1e4 year
old children (N ¼ 83).

Combined Sensory play Non-food sensory play Taste exposure Control

þ taste exposure þ taste exposure (n ¼ 21) (n ¼ 21)
(n ¼ 21) (n ¼ 20) Mean (SD) Mean (SD)
Mean (SD) Mean (SD)

Lychee likedb 1.37(1.46) 2.32(2.06) 0.94(2.05)* 1.33(1.85)

Raspberry likedc 0.53(1.62)* 0.24(1.37)* 0.13(2.31) 0.70(1.34)
Banana likedd 0.83(1.86) 0.13(0.64)* 0.75(1.39) 1.55(2.01)
Total fruit liked a 1.12(1.65) * 2.76(2.64) * 0.31(4.06) 0.93(4.07)

Differences relative to the control condition denoted by *, p < 0.05.

All scores are difference scores.
a
Covariates: Child fruit acceptance F(1, 82) ¼ 5.46*, h2p ¼ 0.18 Child age F(1, 82) ¼ 0.03, ns.
b
Covariates: Child fruit acceptance F(1, 82) ¼ 7.97* h2p ¼ 0.10, Child age F(1, 82) ¼ 0.03, ns.
c
Covariates: Child fruit acceptance F(1, 82) ¼ 0.39 nsChild age F(1, 82) ¼ 0.01, ns.
d
Covariates: Child fruit acceptance F(1, 82) ¼ 1.41 ns Child age F(1, 82) ¼ 0.28, ns.

non-food sensory play games across the five week intervention would have greater fruit acceptance than children who received
period in the two sensory play conditions (n ¼ 41), F(4, 156) ¼ 9.45, five weeks of taste exposure or five weeks of non-sensory play. On
p < 0.001, h2p ¼ 0.20, which indicated a large effect size (see Table 4). the whole it was found that the sensory play groups showed a
In particular, games which incorporated clear ‘goo’ and sand were greater increase in enjoyment of fruits post-intervention compared
less enjoyed than games which involved bubble mixture and those to the exposure or control groups. The greatest increase in enjoy-
which involved baby oil and flour (p < 0.05). There were also some ment was found in the non-food sensory play conditions, where
differences in enjoyment of fruit play across the five weeks by children had greater enjoyment of fruits than children in both the
children in the combined sensory play group (n ¼ 21), F(2.55, exposure and control conditions. Children in the combined sensory
45.94) ¼ 3.16, p < 0.05, h2p ¼ 0.15, which indicated a large effect size; play group, which comprised both fruit-based and non-food tactile
the raspberry and passion fruit games were enjoyed less than the sensory play plus fruit exposure, had a slightly increased enjoy-
blueberry, melon and prune games (p < 0.05). ment of fruits in comparison to the control condition but not the
fruit exposure condition. From these pilot findings playing sensory
games with fruit had no additional ‘benefit’ to fruit acceptance than
4. Discussion that given by non-food sensory play. However, the sample size and
the use of fruit which was already liked, may have contributed to
The main aim of the current study was to examine whether this unexpected finding. These findings support previous cross
preschool children taking part in a five week intervention of two sectional research that enjoyment of sensory play with non-food
different forms of sensory play combined with taste exposure substances is related to food neophobia (Coulthard & Thaker,
2015; Coulthard & Sahota, 2016; Neederkorn et al., 2015).
Table 3 Although we didn't find a clear benefit of fruit play over and above
Associations between enjoyment of the exposure fruit across the five weeks, and non-food play, overall these findings support embedding an
play tasks in the two sensory play conditions in a sample of 1e4 year old children. element of multisensory education into child based fruit and
Fruit game enjoyed Non-food game enjoyed vegetable interventions (Dazeley & Houston-Price, 2015; Hoppu
(n ¼ 21) (n ¼ 41) et al., 2015; Witt & Dunn, 2012).
Blueberry enjoyed 0.71** 0.34*
Within each week, there were strong positive associations be-
Prune enjoyed 0.48** 0.21ns tween enjoyment of the fruit play task, enjoyment of the messy
Raspberry enjoyed 0.63** 0.40* play task and enjoyment of tasting the fruit. This supports and
Passionfruit enjoyed 0.56** 0.46** strengthens previous cross sectional findings that enjoyment of
Melon enjoyed 0.66** 0.55**
messy play tasks is associated with food acceptance. Most previous
p < 0.05*, p < 0.001**.
614 H. Coulthard et al. / Appetite 120 (2018) 609e615
Table 4
Mean enjoyment ratings of the sensory play games across the five weeks in a sample of 1e4 year old children.
Week 1
Fruit Blueberry
Fruit sensory play condition (n ¼ 21) 3.62(0.86)
Substance Bubble mixture
Both sensory play conditions 4.41(0.92)
(n ¼ 41)
studies have examined children on one testing occasion, sometimes
with only two substances (Coulthard & Sahota, 2016; Coulthard &
Thaker, 2015) or with a variety of food and non-food substances
(Nederkoorn, Jansen, & Havermans, 2015). Often these studies have
examined global enjoyment of touching messy substances with
parental reports of food neophobia. This study examined enjoy-
ment of non-food sensory play across substances ranging in texture
from a familiar bubble mixture to ‘goo’ which is slimy and leaves a
trace on the hands. It could be argued that certain textures are more
likely to elicit disgust responses (Martins & Pliner, 2006), and that
slimy textures are more similar to foods that have started to spoil
and rot. In both fruit and non-food conditions, the games that were
least liked by the child participants were those that were gooey or
slimy, in particular the games that involved goo or passion fruit,
which has an unusual texture of seeds in a glutinous pulp. It is
possible that the dislike of gooey, slimy substances is culture spe-
cific, and dependent on the food environment, as some national
cuisines do contain commonly consumed foods with a more
glutinous texture. It would be interesting to examine whether
dislike of the feel of gooey and slimy substances varies according to
familiarisation with these substances in foods. It may be that any
substance which leaves a residue on the hand is liked less than
‘cleaner’ substances.
The main limitation of the present study was that, as this was a
pilot intervention, there were relatively small sample sizes in the
experimental conditions. One of the reasons for the small sample
size was that we delivered the intervention to one child at a time
within the playgroup setting. This meant that we could examine
differences in the child's enjoyment of the play activities across the
five weeks, and has provided a much richer data set of performance
at each week that is missing from other sensory education studies.
Other intervention studies have used private nursery or preschool
settings, and delivered the intervention to a group (Dazeley &
Houston-Price, 2015; Hoppu et al., 2015; Witt & Dunn, 2012),
which though cost effective does not allow evaluation of the tasks
in more detail. In collecting ratings of all tasks our findings can be
used to plan future interventions in relation to which activities and
substances are likely to be more or less accepted.
The difference between our study and previous research is that
our games are not based on sensory education, which centres on
teaching children about the sensory qualities of the food, for
example different tastes such as sweet and sour, and the smell of
different foods (e.g. Dazeley & Houston-Price, 2015). Rather the
fruits themselves were used as materials to be played with. The aim
of encouraging children to engage with the substance on their skin
was to encourage habituation to the sensory characteristics of the
fruit, without the immediate pressure to try. This desensitisation
method is proposed for use by therapists who work with children
with sensory processing disorders (Dunn, 1997), and also in non-
research nursery groups (Thomas, 2007). There has been no eval-
uation of the effectiveness of using foods as stimuli to desensitise
children to the non-taste characteristics of foods in an empirical
study. It was found, within each week of the intervention, that
enjoyment of fruit play was associated with enjoyment of tasting
the fruit afterwards. We found, generally, that children preferred
Week 2 Week 3 Week 4 Week 5
Prunes Raspberries Passion fruit Melon
2.83(1.62) 2.76(0.87)* 2.29(1.39)* 2.95(1.75)
Baby oil and cornfour Goo (agar agar) Sand Cornflour and water
4.52(0.84) 3.57(1.12)* 3.73(1.49)* 3.85(1.30)
playing sensory games with non-food substances to fruit sub-
stances. This may be because children are taught from an early age
by many parents not to play with their food, and therefore this may
have seemed a ‘naughty’ thing to do, especially as a parent was
present on all occasions. In addition, we found that our group that
received the fruit play intervention had much lower baseline fruit
acceptance and were a slightly younger sample. Although age was
not associated with food acceptance in the sample as a whole,
baseline fruit acceptance was associated with taste exposure
enjoyment and with enjoyment of fruits in week 6. Therefore, the
slightly poorer performance of this sample could have been due to
sample effects, despite the fact that we controlled for fruit accep-
tance when evaluating differences between the groups at the end of
the intervention. This problem was probably accentuated by the
small ‘n’ in each condition, which reduced statistical power. In the
future it would be crucial to examine in greater detail the short
term effects of getting children to play games with fruits and veg-
etables prior to tasting in a larger sample size with a control group
that has been matched for child age and baseline food acceptance
variables.
Exposure techniques in young children usually suggest repeated
presentation of the food to increase liking (Birch et al., 1987; Holley
et al., 2015). We offered a variety of exposure, with a different novel
fruit each week, which in itself is known to promote acceptance of
novel foods in infants (Coulthard, Fogel, & Harris, 2014; Maier-
No€th, Schaal, Leathwood, & Issanchou, 2016) but may not have
been enough to increase liking for the fruits in this preschool group.
It was clear from the findings that the variety of fruits liked was
associated with the outcome liking of familiar and novel fruits. If we
had exposed each child to the same five novel fruits each week, and
had used all five novel fruits in the sensory games, perhaps may
have led to greater effects relative to the control group. In addition,
this play intervention was based on fruit consumption rather than
vegetable and fruit consumption. It is widely accepted that vege-
tables are less liked as a food group, partly because they generally
contain less sugar and calories than fruits, and sometimes have a
bitter back taste (Caton et al., 2012; Cooke et al., 2003). The ratio-
nale for using fruits was largely pragmatic; they are easier to pre-
pare and buy in ready-prepared packs for testing in a playgroup
environment. In addition, fruits tend to have softer, juicy textures,
which are ideal for games which aim to leave a trace of substance
on the skin. Interestingly Dazeley and Houston-Price (2015) found
in their sensory education tasks that engagement in the activities
led to greater touching and tasting of vegetables but not fruits. This
may be because some of the fruit stimuli in their study were
challenging, such as rhubarb, which is rarely eaten raw because it is
very astringent whereas their vegetables were more palatable and
similar to familiar foods, such as sweet potato. It is important that
future research should examine sensory tactile play with vegeta-
bles, and whether game-based tasks can encourage initial tasting
and liking in this more challenging food group.
5. Conclusion
This pilot intervention study is one of the first studies to
 H. Coulthard et al. / Appetite 120 (2018) 609e615
examine whether sensory play and taste exposure increases tasting
and enjoyment of fruits. Although there were some differences in
the baseline characteristics of the groups, it seems that generally
sensory play interventions combined with exposure lead to greater
enjoyment of fruits than the exposure alone or control conditions.
Future research would need to examine whether interventions of
this nature can be developed for preschool providers and by par-
ents in the home environment. Further studies are needed to
examine the particular barriers to fruit and vegetable acceptance in
children who are more neophobic and have lower baseline accep-
tance of fruits and vegetables. What is clear is that non-taste, game-
based tasks, which are fun and engaging for young children, may be
an excellent way to introduce children to novel foods, and reduce
the number of exposures needed for preference to occur.
Funding disclosure
This study was funded by a grant from the Feeding for Life
Foundation, which is funded by Danone. The funders had no role in
the inception, design, results or write up of this study.
Conflicts of interest
Danone manufactures commercial formula milks and baby
foods.
The authors have no conflicts of interest.
Appendix A. Supplementary data
Supplementary data related to this article can be found at
https://doi.org/10.1016/j.appet.2017.10.011.
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