Blackwell Science Ltd Use of chopsticks in Chinese children Sheila Wong Kingsley Chan - PDF document

© 2002 Blackwell Science Ltd Use of chopsticks in Chinese childrenSheila Wong,Kingsley Chan,Virginia Wong and Wilfred WongDepartment ofPaediatrics,The University ofHong Kong,Queen Mary Hospital,Pokfulam,Hong KongAccepted for publication 21 November 2001Abstract S.Wong 
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 ,2,157Ð161delicate sushi or quail egg with the pointed Japanesechopsticks.The Koreans and Thais use ßat stainlesssteel chopsticks.The Vietnamese use Chinese-stylechopsticks.Chopsticks are the main eating tool in Chinesecommunities,and every child needs to learn thetechnique for holding and manipulating them.Apair ofchopsticks is the primary tool for eating,andthe physical movements ofcontrol are familiar toChinese.The Chinese use chopsticks as naturally asCaucasians use knives and forks.An analogy ofchopsticks is as an extension ofoneÕs Þngers.Chinese food is prepared so that it may be easilyhandled with chopsticks.In fact,many traditionalChinese households do not have forks at home.For children,use ofchopsticks plays an impor-tant role in the acquisition and development ofeating skills.Their Þngers need to work in a co-ordinated fashion,and they requires good visualmotor co-ordination.This comprises a major Þnemotor developmental milestone in childhood.Theuse ofchopsticks has been deeply integrated intoChinese culture.It became family bound and repre-sented their respect for a person.Every member inthe family should have at least one pair ofchop-sticks especially during important festivals.Eventhose family members who were away from homeshould have a pair ofchopsticks on the tablereserved for them,including the deceased lovedThe Functional Independence Measure in chil-dren (WeeFIM) has been standardized to assess thelevel offunctional independence in children (Msalletal.1994).It was developed by the USA NationalTask Force for Rehabilitation to assess disability inchildren aged 6months to 7years.WeeFIM consistsof18 items,with a seven-level ordinal scale forassessing a childÕs performance in three domains(self-care,mobility and cognition) (Wee FIM System Clinical Guide 2000).Cultural factors play an important role in differ-ent countries.The eating tool for Chinese is differ-ent from that for Americans,so that the tools forassessing the WeeFIM ÔeatingÕitem may not beapplicable to Chinese children.It is important for usto know the developmental level for Chinese chil-drenÕs manipulation ofchopsticks.However,thereis no normative data on the acquisition ofchop-sticks manipulation.We are interested to know theage ofdeveloping the skills ofchopsticks manipula-tion,its relationship to WeeFIM and other demo-graphic data.Therefore,during our pilot study ofestablishing a normative database ofWeeFIM inChinese children,we tried to obtain data on the useofchopsticks as well (Wong etal.2001).Subjects and methodSubjectsNormal Chinese children were randomly selectedfrom three out of15 Caritas kindergartens and fourout of36 Maternal and Child Health Centres in all19 districts ofHong Kong.The mothers were inter-viewed by two medical doctors (SW,KC).Writtenconsent was obtained from the parents.These chil-dren had passed the developmental screening testsrelevant for their ages (at 6,12,18,36 or 60months)conducted in the Maternal and Child Health Centres targeted for all children in Hong Kong.This research was approved by the ethics committeeofthe University ofHong Kong.They were normalchildren without developmental delay or participa-tion in any rehabilitation programmes (Eating score (ES)The WeeFIM ÔeatingÕitem using the American normwas scored.Eating task is deÞned as follows:(1) useofsuitable utensils such as a spoon or fork and cup;(2) bring food and liquid to the month;(3) prepar-ing and moving food and liquid for swallowing;and(4) swallowing.A score ofseven levels was assignedaccording to the degree ofindependence the childcan perform.A Likert scale of7 was assigned for ESaccording to the degree ofindependence the childcan achieve:fully independent;need for an assistive device,modiÞed food or ßuid consistency,or more than a reasonableamount oftime needed or concern for safety;need ofsupervision or cueing;minimal assistance (i.e.child performing75Ð99% ofthe eating task);moderate assistance (i.e.child performing50Ð74% ofthe eating task); Use of chopsticks in Chinese children© 2002 Blackwell Science Ltd, 

 ,2,157Ð161maximal assistance or child performing onlyless than halfthe eating task;total assistance.Chopsticks manipulationDuring our pilot study in collecting WeeFIM datafor normal Chinese children,we had the impressionfrom the mother or chiefcaretaker that most chil-dren who can manipulate chopsticks obtained ascore of4 or above for the eating item oftheWeeFIM and that children were seldom allowed touse chopsticks alone for eating in the early age oflife.They started to use chopsticks as an add-onitem with spoon initially.In Hong Kong,the familytrained their children to use a Western spoon ini-tially and added chopsticks when they found thattheir children were more competent.The typicalChinese spoon is different from the Western spoon.A Chinese spoon is mainly designed for drinkingsoup from a bowl.In the typical Chinese familymeal,all the dishes are placed out ofreach ofchil-dren in the middle ofa non-revolving table,andadults or older children with enough arm lengthhad to pick up the food from the plates at a distance.Chopsticks score (CS)In view ofthe above observation,we decided toassign a CS of1 for those children who could usechopsticks alone for eating in whatever manner andcould Þnish up more than halfthe meal when thefood was well prepared and placed in front ofthem.A CS of0 implied that the child had not acquiredthe skill ofusing chopsticks alone for eating or Þn-ishing up to halfthe meal.Mode ofinterviewFace-to-face interview with the mothers for a sim-ple ÔyesÕor ÔnoÕanswer about the ability to use chop-sticks for Þnishing more than halfthe meal wasconducted by SW and KC.The same standard ques-tion was asked:When food is prepared (e.g.cut orchopped into pieces) and placed in front ofthechild,can your child use chopsticks to Þnish upmore than halfthe meal in whatever way on theirown? Your child can use the chopsticks to scoop thefood into their mouth,pick up tiny bits offood orpierce the food with two chopsticks together in acylindrical grasp.Other demographic data includ-ing sex,occupation ofparents and any domestichelper were also obtained.We classiÞed the familiesinto Þve major social classes (I,professional;II,managerial and technical;IIIn,clerical and minorsupervisory;IIIm,skilled manual;IV,semi-skilledmanual;V,unskilled manual) according to GiddensÕ(1993) classiÞcation.The subjects werethe same subjects used to construct the normativedatabase ofChinese WeeFIM.Inter-rater reliabilityTwenty mothers ofnormal children were inter-viewed independently by two examiners.Inter-raterreliability was calculated using weighted kappas forCS and ES with a result of1.In addition,interclasscorrelation coefÞcients obtained for total scores inthe self-care domain was 0.99.Statistical analysisAnalyses were conducted using softwarever-sion 6.12 (Cary,NC,USA).Wilcoxon rank sum testand KruskalÐWallis test were used to examine therelationship between the age ofacquiring chop-sticks manipulation and factors such as sex,socialclass and presence ofa domestic helper.PearsonÕscorrelation was used to correlate chopsticks scorewith eating score.A signiÞcance level of0.05was used for analyses.A total of445 children,aged 6months to 7.25years3.1years;standard deviation1.87years)was recruited.The boy:girl ratio was 0.57:0.43.Forchopsticks score,194 (44%) scored 1.The mean andmedian age for attaining a CS of1 was 4.6years and4.25years (Fig.1).Demographic factorsThere was a statistically signiÞcant relationshipbetween CS and age (Fig.1).The mean age for S.Wong 
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 ,2,157Ð161achieving a CS of1 was 4.6years (median4.25years;SD1.13years).As for a CS of0,the mean age was 1.9years (median1.5years;1.41years) (0.0001).There was no signiÞ-cant relationship between CS and sex,social class orthe presence ofa domestic helper using theKruskalÐWallis test.Correlation ofchopstick score with WeeFIMÔeatingÕscore (Fig.2)There was strong correlation between CS andWeeFIM eating score (PearsonÕs correlation coefÞ-0.0001).For achieving a chopsticksscore of1,the mean WeeFIM eating score was 5.63Our data suggest that the mean age ofusing a pair ofchopsticks to Þnish most ofa Chinese meal was4.6years for Chinese children.In other words,by5years,most children can use a pair ofchopsticksfor eating.During the interview,we were impressedthat parents ofour children answered our questionsas ÔOfcourse! My child is very clever;he couldmanipulate chopsticks 1year ago.He is better thanhis cousins!ÕIt seemed that many parents use chop-sticks manipulation as their own standard ofassess-ing their childrenÕs ability.Chopsticks are alwaysavailable in Chinese families in Hong Kong.It canbe quite alarming to parents iftheir children stillfailed to use chopsticks at,say,5years old.For paediatricians,it is our role to differentiate lack ofexposure or practice from genuine develop-mental delay and decide on the time and plan ofWeeFIM was originally designed for use in American children,using forks and spoons forassessing ÔeatingÕscore.When we tried to correlatethe two issues together,there was a signiÞcant relationship between achieving independence inWeeFIM ÔeatingÕscore and chopsticks score.For the majority ofchildren with a chopstick score of1,their eating score was above 5 (i.e.nearly There have been a few accidents related to chop-sticks (Kuroiwa etal.1995;Lung etal.1995;Matsumoto etal.1998).Our study demonstratedthat Chinese children started to use chopsticksindependently at quite an early age.Whether occa-sional accidents with chopsticks make parents hesi-tant to let children master the skills much earlierneeds to be explored further.Although our study provided a normative data-base for achieving chopstick manipulation,we onlyclassiÞed the score to either 1 or 0 in an Ôall or noneÕfashion.In future research projects,we plan to studythe age ofattaining different ways ofholding chop-sticks,e.g.cylindrical,scissoring or the mature tri-pod approach.In addition,for those who can usechopsticks,we will explore whether they prefer touse the Western style (spoon,fork or knife) or thetraditional Chinese style ofpurely chopsticks in Þn-ishing an ordinary Chinese meal.AcknowledgementsWe appreciated the help from the Department ofHealth (Maternal and Child Health Centres:Dr Figure1.Schematic plots ofchopsticks score vs.age. Figure2.Comparison ofWeeFIM eating score withchopsticks score. Use of chopsticks in Chinese children© 2002 Blackwell Science Ltd, 

 ,2,157Ð161Constance Chan,Dr Lai,Miss Lee,Miss Lam andthe nursing team in Chai Wan,North Point,CheungSai Wan and Shatin Centres);Caritas kindergartens(Chai Wan,Hong Yau,Kai Yau and Ling Yuet Sin);and Annie Chan,Shum Yee Han and Shum Oi Hanfor technical assistance.ReferencesGiddens,A.(1993) StratiÞcation and Class Structure inSociology,2nd edn.Polity Press Oxford,pp.221Ð226.Kuroiwa,T.,Tanabe,H.,Ogawa,D.& Ohta,T.(1995)Chopstick penetration ofthe posterior cranial fossa:case report.Surgical NeurologyLeung,C.M.,Poon,C.Y.& Lo,M.K.(1995) ChopsticksSingapore Medical JournalMatsumoto,S.,Hasuo,K.,Mizushima,A.,Mihara,F.,Fukui,M.,Shirouzu,T.& Masuda,K.(1998)Intracranial penetrating injuries via the optic canal.American Journal ofNeuroradiologyMsall,M.E.,Digaudio,K.M.,Duffy,L.,Laforest,S.,Braun,S.& Granger,C.V.(1994) WeeFIM.Normativesample ofan instrument for tracking functional independence in children.Clinical PediatricsRed Zen Company (2000) Fine lacquerware chopsticks.Homepage.How were chopsticks invented?http://www.redzen.com/index.html.WeeFIM (2000) System Clinical Guide,version 5.01.Uni-versity at Buffalo,Buffalo,NY.Wong,V.,Wong,S.,Chan,K.& Wong,W.(2002) Func-tional Independence Measure (Wee FIM) for Chinesechildren:Hong Kong cohort.Pediatrics