an investigation of two parental involvement roles in the treatment of obese children

An Investigation of Two Parental Involvement Roles in the

Treatment of Obese Children

Allen C. Israel, Ph.D Lauren C. Solotar, Ph.D.

Elana Zimand, M.A.

(Accepted 22 July 1989)

In a behavioral weight loss program for children, parental involvement in two different roles (i.e., helper or weight loss) was compared for an extended period of time. The helper role targeted behaviors that specifically facilitated the child's weight-loss effort, while the weight loss role involved a parental weight reduction program that paralleled that of the child. Parents were monitored in their respective roles for half a year. Findings suggest a slight superiority for the helper condition during extended treatment, however, there was no difference in overall rates of success or child's weight status at a one-year follow-up. I t was suggested that poor adherence to the parental role could be a contributing factor to the lack of difference found between conditions. The results are discussed in terms of parental roles, the challenge of increasing long-term parental adherence, and improvements in adherence assessment.

The involvement of significant others in treatment has been of interest to in- vestigators in a number of areas. In the adult weight reduction literature, this has been explored through examination of the role of spouse involvement (Brownell, Heckerman, Westlake, Hayes, & Monti, 1978; Israel & Saccone, 1979). In the area of childhood obesity, the role of parental involvement has been the central focus (Israel, 1988). Explicit training of parents in child management skills has been one way that the role of the parent has been explored (Israel, Stolmaker, & Andrian, 1985). Investigations of parental control of contingencies for the child's behavior and the focus of reinforcement (child versus child and parent) have been conducted also (Epstein, Wing, Koeske, & Val-

Allen C. Israel, Ph.D., is a Professor Department of Psychology at the University of Albany; Lauren C. Solotar, Ph.D., is a Clinical Psychologist in the Department of Child Psychiatry at the New England Medical Center's Hospital, and Elana Zimand, M. A., is an advanced doctoral student in the Department of Psychology at the University at Albany. Address correspondence and reprint requests to first author at Psychology Department, University at Albany-SUNY, 1400 Washrngton Avenue, Albany, N Y 12222, USA.

Interndtional lourndl of Eating Disorders, Vol. 9, N o . 5, 557-564 (1990) 0 1990 by John Wiley & Sons, Inc. CCC 0276-3478/90/050557-08$04.00

558 Israel, Solotar, and Zimand

oski, 1986; 1987). Parental involvement has been operationalized also in terms of the child or parent attending treatment alone or together (Brownell, Kelman, & Stunkard, 1983; Kingsley & Shapiro, 1977; Kirschenbaum, Harris, & Tomar- ken, 1984).

Most programs explicitly acknowledge that the treatment of childhood obesity requires changes in the parent’s weight-related behaviors as well as the child’s. The parent’s behavior may influence the child’s success by creating en- vironments, which are more or less facilitative, by modeling, or by direct parental behavior influence. When the parent has been addressed explicitly in treatment programs it has been most often through the mechanism of parental weight loss. In this role, the parent begins a weight-loss program of hisiher own that parallels that of the child (cf. Epstein, ‘ding, Koeske, Andrasik, & Os- sip, 1981). Israel, Stolmaker, Sharp, Silverman, and Simon (1984) reported on an evaluation of two modes of parental involvement. The weight-loss role (which targets parental behaviors evolving from a parallel weight-loss program) was compared to a helper role that focuses on the parent’s behaviors that would assist directly the child without targeting parental weight loss. Both forms of parental involvement were equally successful in producing weight loss among children during treatment and were superior to a wait-list control. The two procedures also yielded equivalent results at a one-year follow-up.

The present investigation was designed to expand upon these findings. Par- ents in the previous research group were involved in their respective roles for only the last 4 weeks of treatment. They were encouraged then to continue their roles during the l-year follow-up period. However, the only intervention during this period was occasional planned contacts during which continuation in role was encouraged. It is possible that the obtained equivalence of the two roles was a function of the brief opportunity to operate in this role under the regular supervision of the program. The present investigation, therefore, con- siderably expanded the time period during which the parents were asked to practice and were evaluated in these roles. There is accumulating evidence suggesting the need for extended treatment involvement in order to obtain change in weight-related behaviors (Epstein & Wing, 1987; Perri, 1987).

An additional feature of the current investigation was an exploration of the actual adherence to these respective role behaviors and the relation of such adherence to treatment outcome. That is, to what extent do parents adhere to rec- ommended parental behaviors? Is adherence different for the two conditions? Is adherence to parental role related to child weight loss? Examining this spe- cific aspect of adherence also adds to accumulating information regarding adherence to the child’s weight-loss program (Israel, Silverman, & Solotar, 1987; 1988).

METHOD

Subjects

Forty children ranging in age from 9 years, 5 months to 13 years, 4 months (x = 11 years, 4 months) participated in treatment with at least one of their parents. Eligibility requirements were that children 1) be at least 20% above

Parent Involvement and Child Weight Loss 559

ideal weight for height, age, and gender, 2 ) obtain a medical release, 3) have no involvement in other weight or psychological treatment(s), and 4) have at least one parent who agreed to attend all treatment and measurement sessions. Participants were recruited through referrals from local medical personnel, school health personnel, and notices through local school systems.

Procedure

Separate child and parent groups comprised of members from four to eight families met for an orientation session followed by eight-weekly 90-minute sessions. This constituted the intensive phase of treatment. Extended treatment consisted of six additional sessions over the next 18 weeks, with increasing time intervals between sessions. The entire treatment period, following orientation, was 26 weeks. Measurements were obtained also 1 year following the completion of extended treatment.

The treatment was a behavioral program based on the 4-prong CAIR (cues, activity, intake, and reward) approach described in previous reports (cf. Israel et al., 1984; Israel, Stolmaker, & Andrian, 1985). In addition to the basic intervention program designed to produce weight loss in the child, the parents, in consultation with staff, were required to select one of two roles at Week 4 of treatment. This role then became the mechanism for the parent’s behavior change efforts. Parents were allowed to select their roles rather than be as- signed to them so as to increase the validity of these procedures. Choosing one’s role was viewed as being more like usual clinical situations. Also, assignment of non-overweight parents to a role in which they focused on their own weight-related behaviors might lack face validity. Many overweight parents also voiced concern about their own ability to lose weight and the damage this might create for the child’s weight-loss efforts. These considerations suggested adoption of the current assignment strategy.

Parents could choose to engage in their own weight-loss effort (Weight Loss (WL) condition). If a parent selected this option they then agreed to engage in a weight reduction program that paralleled that of their child. These parents monitored behaviors and engaged in behavior change efforts in the four CAIR areas described above. Weekly-habit records included items such as staying below prescribed calorie limit, meeting a physical activity goal, and eating in only one place. Alternatively, parents could choose to target those behaviors that would facilitate directly their child’s weight-loss effort (Helper (H) condition) and not engage in their own weight-loss effort. Weekly-habit records in this condition contained items such as helping their child fill out eating records, keeping high calorie foods out of sight, and making low calorie snacks available. Thus, in one condition (WL), parental involvement was programmed explicitly by targeting the parent’s own weight loss behaviors, whereas programming in the other condition (H) explicitly targeted behaviors directed at assisting the child’s weight-loss efforts. Parents in the Helper condition were not involved in their own weight-loss efforts. They did not monitor their own weight-related behaviors nor were contingencies based on this. Parents in the WL condition, on the contrary, did not monitor their helping behavior explicitly nor were these behaviors the focus of change efforts or contingencies.

In both the WL and H conditions, reward contracts were set up (like those


for the child), whereby the child and parent contracted for the parent to receive rewards based upon performance of appropriate weight loss or helper behaviors. Parental functioning in respective roles was prescribed and monitored through Week 26.

Assessment of Adherence

Degree of adherence was scored based on the parent’s weekly habit record. A measure of total overall adherence was calculated for each parent. The score for overall adherence was calculated as a percentage since actual assignments vary from week to week. This score, therefore, indicates the proportion of adherence for a particular week and allows direct comparison and combination of weekly scores. Two independent raters scored all adherence records. Reliabil- ity for overall adherence was high ( r = .95).

RESULTS

Table 1 presents the mean percentage overweight for the 40 children completing treatment through Week 26. Percent overweight, rather than absolute weight, was selected as the dependent measure since the children are in a period of expected growth. A 2(Condition) x 2(Week 8 and Week 26) analysis of covariance with Week 1 as the covariate, conducted on the child’s percent overweight, yielded a significant condition by time interaction (F(1,38) = 4.23, p < .04), but no significant main effects. There was a significant decrease in the percent overweight between Weeks 8 and 26 for the Helper children (t(27) =

Table 1. children’s percent overweight during treatment and follow-up

Means and standard deviations for

Treatment

Condition Week 1 Week 8 Week 26

Helper 42.2 34.2 32.5 (n = 28) (16.4) (17.7) (19.0) Weight Loss 51.9 39.8 40.8 (n = 12) (17.2) (16.8) (17.8)

Follow-up”

Condition Week 1 Week 26 1 Year

Helper 42.8 30.9 38.4 (n = 24) (17.4) (20.1) (24.7)

(n = 11) (18.0) (17.6) (24.81 Weight Loss 51.8 39.1 47.7

Note. Numbers in parentheses are standard deviations.

”Data presented in the follow-up section includes only those participants who completed the 1-year follow-up.


3.61, p < .U1) and a nonsignificant increase for WL children. These findings suggest a slight superiority of the Helper condition during the extended treatment period. During the treatment period, WL parents lost an average of 11.46 lbs. (range: - 65.50-+ 3.00).

Five of the families completing treatment (4 H, 1 WL) dropped out during the follow-up period. A separate 2(Condition) x 3(at Weeks 8, 26, and 1 year) analysis of covariance with Week 1 percent overweights as the covariate, was conducted for the children for whom all measurements were available. A significant effect for time emerged (F(2,66) = 8.09, p < .001), but neither the main effect for condition nor the interaction was significant. The mean weight mea- sures for the 35 children included in this analysis are presented in Table l also. An additional 3 condition analysis derived by dividing the Helper children into two groups based on whether or not their attending parent was overweight ( n = 11 and 13, respectively) yielded no conditional differences and, thus, parallel findings described above. Therefore, the 2 condition analysis was retained as the principal means for examining findings.

The differential effectiveness of the two parental involvement conditions was evaluated also by examining the question of whether the two conditions resulted in different rates of success and failure. Success during the intensive phase of treatment was defined by a loss of 1/2 lb per week, the programmatic suggested rate of weight loss (H = 21/28 versus WL = 11/12). Success over the entire treatment period was defined as a decrease in percent overweight between Weeks 1 and 26 (H = 25/28 versus WL = 9/12). Success during the follow-up period was defined as a maintenance or decrease in percent overweight between Week 26 and the one-year follow-up (H = 5/24 versus WL = 4/11). Chi-square analyses were performed comparing the rates of success in the H and WL conditions during each of the periods defined above. None of these comparisons indicated significant condition differences. A similar analysis comparing the number of children achieving nonobese status by the 1-year follow-up (H = 5/24 versus WL = 2/11) also indicated that the two conditions did not differ.

Regarding changes in parental weight status, a 2(Condition) x 3(at Weeks 8, 26, and 1 year) analysis of covariance with Week 1 percent overweights as the covariate was conducted for WL parents and overweight H parents. Neither the main effects for condition or time nor their interaction was significant. Mean weight change for WL parents between week 26 and 1 year was +0.68 (range: -27.25-+26.26). The comparable change for overweight H parents was +0.94 (range: - 7.50 -+ 6.25).

Pearson correlations between change in child and parent weights were calculated for families in which the attending parent was overweight. Correlations between child and parent changes in percent overweight for the WL condition, although not significant, showed a pattern of increased association as program contact was reduced from intensive treatment, to extended treatment, to follow-up (r(12) = .06, p = .43; r(12) = .34, p = .14; and r(l1) = .43, p = .09, respectively). For families in the H condition, however, increased correlation was evident during extended treatment, but not during follow-up (r(14) = - .12, p = .34; r(13) = .40, p = .09; and r(9) = -.lo, p = .40, respectively). The levels of these correlations suggest caution, however, the patterns are of interest. They may suggest that the weight-loss role enhances the association be-


tween parental and child patterns of weight change during periods of minimal therapeutic contact.

Table 2 presents the mean adherence for H and WL parents during the intensive phase of treatment (Weeks 4-8) and during the extended phase of treatment (Weeks 9-26). A 2(H versus WL) X 2(intensive versus extended treatment) analysis of variance indicated a main effect for time (F(1,24) = 39.56, p < .001) but no main effect for parent role and no significant interaction. As indicated in Table 2, reported adherence drops significantly during the extended period for both conditions.

The relationship between degree of adherence to parental role and change in child’s weight status was examined also. Correlations between adherence and changes in child’s weight status during comparable periods were calculated for all subjects combined and separately for H and WL families. None of these correlations proved significant.

DISC USSlON

The comparisons between children whose parents selected the helper or weight loss roles indicate a conceptual replication and extension of previous work (Israel et al., 1984). Both roles were associated again with equivalent weight loss for children during intensive treatment. With additionally super- vised time in the role provided during extended treatment, there was an indi- cation of greater success for children whose parents were in the helper role. However, a number of considerations, discussed below, suggest caution in conclusions regarding this trend. In addition, even if a trend toward the superiority of this role were emerging, the present results indicate that it did not continue during the no-treatment, follow-up period. Both conditions resulted in comparable changes in child weight status during follow-up. Indeed, the failure of the majority of children to maintain treatment gains is disappointing. It seems likely that additional interventions are needed to improve long-term outcome and it might be the case that under such conditions differences in parental role might emerge. For example, it is possible that poor adherence to parental role is one of the basic factors contributing to these outcomes. Perhaps continued or higher level adherence to the helper role might have produced significant long-term outcomes. Regarding the parental weight-loss strategy, there is other support consistent with such a conclusion. A number of investi-

Table 2. Mean percentage adherence to parental role for intensive and extended treatment phases

Condition Weeks 4-8 Weeks 9-26

Helper 57.1 16.1 (n = 19) (33.3) (16.8) Weight Loss 55.8 24.5 (n = 7) (30.8) (25.8)

standard deviations. Note. Numbers in parentheses indicate


gators report greater correlations of parental and child weight-change during follow-up (Epstein, Wing, Koeske, & Valoski, 1985; Israel et al., 1985; 1986). This finding of greater association between child and parent weight-change during periods of reduced or limited contact was evident in the present sample. It should be noted that this occurred for the WL but not the H condition. As suggested earlier the WL parental role may be a high risk strategy in that it ”ties” child success more clearly to parent weight-loss.

The rapid drop-off in reported levels of parental adherence in the present study is clearly problematic. Although there is some suggestion of a relationship between parental adherence and one’s weight loss over time, the lack of correlation between overall levels of reported adherence to parental role and child weight-change creates similar concerns. It is, therefore, probably unwise to draw any firm conclusions concerning the mechanisms of change based on these findings. The size of the present sample may be one factor restricting possible findings of significant correlation. It is also well to remember that the definition of adherence in the present instance relied entirely on scoring of parental monitoring records. It is conceivable that some parents continued in their roles but decreased their recording behavior. Clinical impressions and the continued progress of at least the ”helper” children during tE,e extended treatment period seem consistent with such an interpretation. The different patterns of correlation between parent and child weight-changes in the H and WL conditions is also consistent with such an interpretation and may suggest a greater ease of adherence for the helper role. However, the present findings suggest the importance of improving recording behavior and/or obtaining additional indices of parental adherence in order to examine these and other ques- tions.

There are several other findings worthy of note in interpreting the current findings. In the earlier group of families (Israel et al., 1984) 64% of the parents selected the Weight-Loss role. In contrast, in the present sample 70% selected the Helper role. It is difficult to know what this shift reflects. It is clearly not, however, a function of differential influence by program personnel. Neither is it the case that fewer parents were overweight, making the weight-loss role a less likely option. In the earlier sample, 75% of the overweight parents selected the weight-loss role compared to only 43% in the present sample. Our conjec- ture is that this pattern is due to some recent shifts in attitude among the parents regarding their own likely success at weight loss. The implication for the current findings of this shift was that fewer parents selected the weight-loss role, resulting in a small sample size.

One final comment relates to the research strategy choices of allowing families to select one of the two parental involvement roles rather than employing random assignment. This choice was made to provide greater external validity to non-research clinical contexts, and because it was believed that “forcing” the weight-loss role was not neutral. Many of our families had in the past ex- pressed a desire to make this an effort for the target child and to avoid what they felt was a likely failure of parental weight-loss. While certainly non-random assignment may yield a variety of unintentional group differences, the one of principal concern would be group differences in parental weight-status. The extreme case would be if all WL parents were overweight, whereas all H parents were not. Indeed, approximately half of the parents in the helper role


were overweight. Analysis of the present data suggest that parental weight status does not alter conclusions regarding the impact of the two parental roles.

The present findings, then, would seem to support at minimum the viability of the helper role as an alternative to the usual parental weight-loss-strategy. Indeed, it may have certain advantages in light of the difficulties of long-term weight loss in adults. However, long-term adherence to parental role in general, not just for a parental weight-loss strategy, remains a challenge in terms of both measurement and clinical practice.

This research was supported in part by Grant Number 5ROlHD13460 awarded by the National Institutes of Child Health and Human Development.

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an investigation of two parental involvement roles in the treatment of obese children

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