child and parent factors that influence psychological problems in obese children

Child and Parent Factors that Influence Psychological Problems in Obese Children

Leonard H. Epstein Karla R. Klein

and Lucene Wisniewski

(Accepted 5 April 1993)

This study assessed the influence of child and parental obesity and parental psychiatric symptoms on psychological problems in obese 8-17-year-old children. Child psychological problems were measured using the Child Behavior Checklistl4-18, whereas adult psychiatric symptoms were measured using the Cornell Medical Index. Multiple linear regression analyses showed parental psychiatric symptoms were related to child psychological problems for six of eight problem behavior scales. Child obesity made no independent contribution to child psychological problems, and parental obesity was related to child problems on only one scale. The most prevalent problems were Anx- ietylDepression for 75% of the boys and Social Problems for20% of the boys and 12.8% of the girls. These results suggest a broader conceptualization of factors that influence behavior problems of obese children than their degree of obesity. 0 1994 by John Wiley & Sons, Inc.

Studies investigating the relationship between childhood obesity and psychological problems have produced mixed results. Despite ample evidence documenting the social stigmatization of obese children (Counts, Jones, Frame, Jarvie, & Strauss, 1986; Good- man, Richardson, Dornbusch, & Hastorf, 1963; Lerner & Gellert, 1969; Maddox, Back, & Liederman, 1968; Richardson, Hastorf, Goodman, & Dornbusch, 1961; Strauss, Smith, Frame, & Forehand, 1985; Staffieri, 1967) negative psychological effects of being obese have not been consistently documented. For example, contradictory results have been found with regard to children’s self-esteem; with some studies revealing similar levels of self-esteem for obese and nonobese children (Mendelson & White, 1982; Wadden, Fos- ter, Brownell, & Finley, 1984) and others suggesting significantly lower self-esteem for

Leonard H. Epstein, Ph.D., is currently Professor, Department of Psychiatry, University of Pittsburgh School of Medicine, Karla R. Klein is a graduate student in the Department of Psychology, University of Georgia, and Lucene Wisniewski is a graduate student in the Department of Psychology, University of Pittsburgh. Address correspondence to Leonard H. Epstein, Ph. D., University of Pittsburgh School of Medicine, Western Psychi- atric Institute and Clinic, 3877 O’Hara Street, Pittsburgh, PA 75213-2593.

International journal of fating Disorders, Vol. 15, No. 2,151-157 (1994) 0 1994 by John Wiley & Sons, Inc. CCC 0276-3478/94/020151-07

152 Epstein, Klein, and Wisniewski

obese children (Allon, 1979; Sallade, 1973; Strauss et al., 1985). Klesges et al. (1992) showed no cross-sectional relationship between obesity and self-esteem in children, but longitudinally showed physical self-esteem was related to development of body fat for up to 2 years after measurement. Similarly, studies of children’s social and psychological adjustment have yielded inconsistent conclusions varying from no significant difference between obese and nonobese children (Sallade, 1973) to increased problems for obese children (Banis et al., 1988; Israel & Shapiro, 1985; Strauss et al., 1985). The inconsistency of these findings may be attributable to methodological issues such as varying sample characteristics, sample sizes, age ranges, and methods of measurement.

In addition to these methodological issues, the conceptual models used to study mechanisms for psychological problems in obese children should extend beyond child obesity (Epstein, 1985) to parent obesity and parental psychological problems. Psycho- logical problems run in families (Reich et al., 1987) and this concordance may be particularly relevant to families with obese parents, because obese children usually have obese parents (Garn & Clark, 1976), and obese adults who seek treatment for obesity may have an increased incidence of psychological problems (Black, Goldstein, & Mason, 1992; Goldsmith et al., 1992).

The only investigation that assessed the role of child and parent obesity on childhood psychological problems suggested an influence of parental obesity (Israel & Shapiro, 1985). These investigators examined psychological problems in 6-12-year-old obese children using the Child Behavior Checklist (CBCL) (Achenbach, 1978; Achenbach Edel- brock, 1979), a well-standardized measure of child psychological problems. When CBCL subscale scores of obese children were compared to normative samples, the obese children were similar to children referred for treatment on two subscales: boys’ Social Withdrawal and girls’ Somatic Complaints. Correlational analysis showed degree of obesity was not related to any psychological problems. In fact, for several problems less obese boys and girls had higher behavior problem scale scores than more obese children. These investigators found maternal percent overweight was negatively related to boys’ Externalizing, Aggressive, and Delinquent scores, and positively related to girls’ Cruel subscale score. Thus, maternal obesity was independently related to a different set of child behavior problems than child obesity. Paternal obesity was not studied, a serious limitation to understanding the influence of parental obesity on child psychological problems (Phares & Compas, 1992). We know of no study that has assessed the influence of parental psychiatric problems on psychological problems in obese children.

The present study used multiple regression techniques to evaluate the independent and combined effects of child and parental obesity and parental psychiatric problems on child psychological problems using the revised version of the CBCL (Achenbach, 1991).

METHODS

Subjects

Subjects were children and their parents from 59 families screened for participation in a family-based behavioral weight control program. The average child was 10.2 t 1.1 (M t SD) years of age, and 49.0 * 15.5% overweight, with 66% of the sample female. The mothers and fathers were 38.4 +- 4.1 and 42.4 f 6.6 years of age, respectively. Mothers ranged from -21.7 to 132.1% overweight (21.3 +- 28.9), and fathers ranged from -6.0 to 95.9% overweight (28.6 k 21.0). Thus, although the children were obese, parental

Child and Parent 153

weight vaned from lean to very obese. The mean Hollingshead (1975) four-factor index of socioeconomic status (SES) for this sample was 48, indicating that families were generally of middle class status (medium-sized business owners, minor professionals, technicians, etc.). Families were recruited via public service announcements in the me- dia and referrals from pediatricians and school nurses. Criteria for screening included child not diagnosed with attention deficit disorder or learning disability; and no family member currently undergoing psychiatric treatment or participating in an alternative weight loss program.

Measurement

At the screening session parents and children were weighed and measured, and parents completed the SES questionnaire, the revised CBCL for ages P18 years (Achen- bach, 1991), and the Cornell Medical Index (CMI; Brodman, Erdmann, & Wolf, 1956). The CBCL is a well-validated questionnaire, completed by the mother of the participating child. The CBCL was scored using the IBM-PC version of the CBCL computer scoring program to yield three competence scales (Activities, Social, and School), an overall competence score, and eight behavior problem scales scored for both boys and girls (Withdrawn, Somatic Complaints, AnxiousDepressed, Social Problems, Thought Problems, Attention Problems, Delinquent Behavior, Aggressive Behavior). In addition, a Total Problem score, and Internalizing Behavior Problem (Withdrawal + Somatic Complaints + AnxiouslDepressed) and Externalizing Behavior Problem (Delinquent + Aggressive Behavior) scores were calculated. Standardized t scores were used for the multiple regression analysis, and statistical cutoffs for patients samples used to assess the percentage of obese children who meet or exceeded clinical levels for Competence ( ~ 3 3 ) or Behavior Problem (367) subscales (Achenbach, 1991).

The CMI is a 195-item self-report questionnaire that assesses adult physical and psychiatric complaints (Brodman et al., 1956) and was filled out by both parents. The psychiatric items comprise six scales (scales M-R) that assess inadequacy, depression, anxiety, sensitivity, anger, and tension. The total CMI score for all psychiatric scales has been used as a screening device to detect emotional disturbances (Costra & McCrae, 1977) and has been shown to discriminate emotionally maladjusted from normal indi- viduals (Gibson, Hanson, & West, 1967; Ryle & Hamilton, 1962; Verghese, 1970). Cri- teria for significant parental psychopathology were 8 for mothers and 7 for fathers (Stefansson, & Kristjansson, 1985). The CMI is a screening tool to assess parental symptom reports and distress, but it was not designed to provide specific diagnostic infor- mation on parental psychopathology.

Height and weight were measured using a laboratory constructed height board cali- brated in one-eighth inch intervals and a balance beam scale. Percent overweight was based on child (Jelliffe, 1966) and adult (Metropolitan Life Insurance Company, 1983) weight for height norms, All analyses of relative weight were performed using the body mass index (BMI = kg/m2).

This research was approved by the University of Pittsburgh IRB, and informed con- sent was obtained from parents and the child.

Analytic Methods

Multiple regression analyses were used to relate the independent effects of childhood obesity, parent obesity, and parental psychological problems for each of the CBCL child


scales. Each regression analysis included seven variables: child sex, age and BMI, both parent BMI, and each parent total CMI scores for the psychiatric scales. To provide an estimate of the clinical significance of the problems in obese children, the percentage of children who met or exceeded clinical levels for the competence and syndrome subscales was calculated.

RESULTS

Standardized t-scale scores and the percentage of children who met criteria for clinical problems are presented in Table 1. The majority of obese children fell within the normal range of CBCL scores, with 42 of the children having no elevations in any scale (71%). Ten of the children had elevations in one scale, three children in two scales, two children in three scales, and two children with elevations in seven and eight scales, respectively. There were two problems in which more then 10% of the children showed elevated scores, boys with AnxietylDepression (15%) and boys (20%) and girls (12.8%) with Social Problems. Mother and father total CMI scores were 2.6 ? 3.8 and 1.6 ? 2.7, respectively. Ten percent (6/59) of the mothers and 6.7% (4/59) of the fathers exceeded clinical cutoff scores (Stefansson, & Kristjansson, 1985).

The best fitting models relating child sex and age, child and parental obesity, and parent psychiatric symptoms to CBCL subscales are presented in Table 2. Significant models were shown for six of the eight behavior problem scales, the Externality scale and the Total Problem scale. No significant relationships were observed for the Com- petence scales, the Withdrawal and Somatic Complaint Problem scales, and the Inter- nalizing Problem scale.

Neither child BMI nor child sex was independently related to child psychological problems. Child age was related to two behavior problems, Anxiety/Depression and

Table 1. psychological problems (Competence scale scores < 33 and symptom scale score > 67

t-scale scores and percent of obese children who meet statistical criteria for

Boys Girls Boys Girls

M SD M SD N % N %

Competence scales Activities 46.5 6.8 47.8 6.0 Social 55.5 23.7 54.3 18.4 School 50.9 6.6 50.3 6.6 Total Competence 57.8 22.9 55.7 18.0

Withdrawn 53.3 5.6 53.9 5.5 Somatic Complaints 55.1 6.1 54.2 6.0 AnxietyfDepression 55.4 7.7 54.3 5.6 Social Problems 60.1 8.5 58.7 7.2

Attention Problems 52.7 4.7 51.7 4.3 Delinquent Behavior 52.2 5.2 52.9 4.2 Aggressive Behavior 52.2 5.8 52.0 3.8

Behavior problem scales

Thought Problems 52.5 4.7 52.4 4.7

Internalizing, Externalizing, and Total Problem scales Internalizing 50.2 12.0 49.7 10.0 Externalizing 45.7 8.6 47.0 7.9 Total Problems 49.6 9.2 49.4 8.4

Note. Sample includes 20 boys and 39 girls.

0 3 1 1

1 1 3 4 0 1 1 1

2 1 1 -

0 15 5 5

5 5

15 20 0 5 5 5

10 5 5

1 2.6 0 0 2 5.2 0 0

2 .5.2 1 2.6 2 5.2 5 12.8 0 0 1 2.6 0 0 1 2.6

1 2.6 0 0 0 0


Table 2. scale scores

Child and parent variables that relate to Child Behavior Checklist standardized

Beta Weights of the Constant and Predictor Variables

Constant C-Age M-BMI M-CMI F-BMI F-CMI r2 p

Social Total AnxietyDepression Attention Problems Delinquent Behavior Aggressive Behavior Externaling Behavior Problem Thought Problems

57.83 45.59 70.36 50.86 64.04 51.05 44.76 51.57

0.38 1.02 -0.45 1.02 .45 1.05 0.81 2 6

- 1.65 0.74 .16 0.45 .15

-1.19 0.48 .15 0.39 .10 0.69 .10 0.32 .07

<.001 <.001 c.001

.002

.01 ,013 ,013 ,044

~~~~~

Note. The beta weights for significant variables (p < .05) in each model are presented. C = child; M = mother; F = father; BMI = body mass index; CMI = Comell Medical Index. ? and p refer to characteristics of the best fitting regression model.

Delinquent Behavior. The best fitting model was for Social Problems [r2 = .45, F(4,54) = 11.19, p < .001], one of the prevalent problems in this sample of obese children, with the combination of mother and father BMI and mother and father CMI as predictors. The other prevalent problem in this sample, AnxietyDepression, was predicted by a combination of child age and father CMI (2 = .16 [F(2,56) = 5.50, p = .007]. The other significant models shown in Table 2 are as follow: Thought Problems [ r2 = .07, F(1,57) = 4.24, p = .044]; Attention Problems [? = .15, F(1,57) = 10.16, p = .002]; Delinquent Behavior [?- = .15, F(2,56) = 4.97, p = .01]; Aggressive Behavior [? = .24, F(1,57) = 6.57, p = .013]; Externalizing Problems [2 = .lo, F(1,57) = 6.55, p = .013]; and Total Problems (f = .260, F(2,56) = 9.62, p < .001].

Across all problems, maternal CMI scores were related to six scales: Social Problems, Thought Problems, Attention Problems, Aggression, Externalizing Problems, and Total Problem score, whereas paternal CMI scores were related to four scales: Anxiety/ Depression, Social Problems, Delinquency, and Total Problems.

DISC U SSlO N

This investigation showed that parental obesity and parental psychiatric symptoms show stronger relationships to psychological problems in moderately obese children seeking treatment than child sex, age, or BMI. This provides support for our previous hypothesis (Epstein, 1985) that there are multiple pathways that influence psychological problems in obese children (Reich et al., 1987), and that the examination of factors other than the obesity level of the child may be important.

The majority of obese children showed no psychological problems. The two most prevalent problems reported were Social Problems for boys and girls, and Anxiety/ Depression for boys. The regression models for these two problems accounted for a significant amount of variance. The model for the Social Problems subscale included parental psychiatric symptoms as well as parental obesity. It may be relevant that the beta weights for father and mother obesity were in different directions. Children with the most social problems had mothers who were more overweight and fathers who were less overweight. The discrepancy between weight status of the parents may be associ-


ated with an environment that is particularly conducive to development and/or perpet- uation of child social problems.

Scores on the child Anxiety/Depression subscale were related to child age and father psychiatric symptoms. The children with higher scores on the Anxiety/Depression subscale were younger with fathers that had psychological problems. The significant influence of paternal problems may be a function of the elevated prevalence of Anxiety/ Depression in boys. It is possible that if more girls had scored in the elevated range, then maternal problems may have been more important.

Further research should attempt to understand mechanisms that could mediate the influence of parental problems on child problems. Although there has been no empirical research on this problem in obese children, we speculate on two mechanisms that have been studied in other populations. First, based on the observation that psychopathology often runs in families (Crowe, Noyes, Pauls, & Slymen, 1983; Reich et al., 1987), parents may be modeling or arranging an environment that sets the occasion for or directly supports the same problem in their child. This possibility could not be directly evaluated in this study, since instruments that assess the same problem dimensions in parents and children were not used. However, in the present study neither maternal nor paternal Anxiety or Depression scales of the CMI were related to child Anxiety/Depression. It would be interesting in future studies to assess concordance for psychological problems measured the same way in multiple family members.

Another possible mechanism is that parental psychological problems alter parenting behaviors. A large number of studies have shown that parental depression (Forehand, Wierson, McCombs, Brody, & Fauber, 1989; Wahler & Dumas, 1989) and marital conflict (Jouriles & Farris, 1992) influence parent-child interactions, child behavior, and child psychological problems. Thus, the type of parent problem may not be directly transmit- ted to the child, but rather parental problems influence parenting behaviors that impair normal child development. Future studies can test this hypothesis by including measures of parenting behaviors as well as parent problems.

The use of standardized measures of psychological problems, the study of moderately obese children, and the inclusion of both child and parental obesity and parental psychiatric symptoms as predictors of psychological problems are strengths to this study. However, there are several limitations. First, this study is limited to obese children. This truncates the distribution of childhood BMI, and a different relationship between degree of obesity and psychological problems might be observed if a broader distribution of childhood BMI was sampled. Second, the study criteria excluded obese children who had been in current psychological treatment. Thus, results from this sample may un- derestimate behavior problems in obese children. Third, the fact that subjects were pursuing treatment for obesity could also distinguish this obese sample from a general childhood obese population, as has been suggested in obese adults (Black et al., 1992; Crisp & McGuinness, 1976; Goldsmith et al., 1992). These families may be very different from those who do not acknowledge the obesity of their children or who persist in waiting for the child to outgrow obesity. Fourth, the child psychological problem measure was completed by the mother, and there may be differences in ratings of pathology by parent (Achenbach, McConaughy, & Howell, 1987; Webster-Stratton, 1988), and thus differences in the relationship between predictors of pathology and child and/or parent variables. Finally, a general screening measure was used to assess parental psychiatric problems. Based on these limitations, care should be taken before generalizing these results to all obese children. However, these initial results suggest parental problems may be contributing more to child psychological problems more than the degree of


obesity of the child, and additional research with a broader range of obese children and. using more extensive assessments of parental psychological problems is warranted.

This research was supported in part by Grant HD R01 23713 a n d Grant HD R 0 1 25997 awarded to the first author. Appreciation is expressed to Linda Vara and Alice Valoski for assistance in planning and supporting the intervention, to Jim McCurley for assistance in data management, and to Marsha D. Marcus for comments on a n earlier draft of this manuscript.

REFERENCES

Achenbach, T. M. (1978). The Child Behavior Profile: I. Boys aged 6-11. Journal of Consulting and Clinical Psychology, 46, 478-488.

Achenbach, T. M. (1991). Manual for the Child Behavior Checklistl&ld and 1991 Profile. Burligton, VT. University of Vermont, Department of Psychiatry.

Achenbach, T. M., & Edelbrock, C. S. (1979). The Child Behavior Profile: 11. Boys aged 12-16 and girls aged 6-11 and 12-16. Journal of Consulting and Clinical Psychology, 47, 223-233.

Achenbach, T. M., McConaughy, S. H., & Howell, C. T. (1987). Childladolescent behavioral and emotional problems: Implications of cross-informant correlations for situational speaficity. Psychological Bulletin, 101, 213-232.

Allon, N. (1979). Self-perceptions of the stigma of overweight in relationship to weight losing patterns. American Journal of Clinical Nutrition, 32, 47M80.

Banis, H. T., Varni, J. W., Wallander, J. L., Korsch, B. M., Jay, S. M., Adler, R., Temple, E. G., & Negrete, V. (1988). Psychological and social adjustment of obese children and their families. Child Care, Health and Development, 14, 157-173.

Black, D. W., Goldstein, R. B., & Mason, E. E. (1992). Prevalence of mental disorder in 88 morbidly obese bariatric clinic patients. American Journal of Psychiatry, 149, 227-234.

Brodman, K., Erdmann, A. J., &Wolf, H. G. (1956). CornellMedical Indexhealth questionnaire manual. New York Cornell University Medical College.

Costra, P., & McCrae, R. R. (1977). Psychiatric symptom dimensions in the Cornell Medical Index among normal adult males. Journal of Clinical Psychology, 33, 941-946.

Counts, C. R., Jones, C., Frame, C. L., Jarvie, G. J., & Strauss, C . C. (1986). The perception of obesity by normal-weight versus obese school-age children. Child Psychiatry and Human Development, 17, 11S120.

Crisp, A. H., & McGuinness, 8. (1976). Jolly fat: Relation between obesity and psychoneurosis in the general population. British Medical Journal, 7 , 7-9.

Crowe, R. R., Noyes, R., Pauls, D. L., & Slymen, D. (1983). A family study of anxiety disorder. Archives of General Psychiatry, 40, 10651069.

Epstein, L. H. (1985). Family-based treatment for pre-adolescent obesity. In M. K. Wolraich & D. K. Routh, (Eds.), Advances in developmental and behavioral pediatrics (pp. 1-39). Greenwich, ff JAI Press.

Forehand, R., Wierson, M., McCombs, A,, Brody, G., & Fauber, R. (1989). Interpersonal conflict and adolescent problem behavior: An examination of mechanisms. Behaviour Research and Therapy, 27, 365-371.

Garn, S. M., & Clark, D. C. (1976). Trends in fatness and the origins of obesity. Pediatrics, 57, 4-56. Gibson, H. B., Hanson, R., & West, D. T. (1967). A questionnaire measure of neuroticism using a shortened

scale derived from the Cornell Medical Index. British Journal of Social and Clinical Psychology, 6 , 129-136. Goldsmith, S. J., Anger-Friedfeld, K., Beren, S., Rudolph, D., Boeck, M., & Aronne, L. (1992). Psychiatric

illness in patients presenting for obesity treatment. International Journal of Eating Disorders, 22, 63-71. Goodman, N., Richardson, S. A., Dornbusch, S. M., & Hastorf, A. H. (1963). Variant reactions to physical

disabilities. American Sociological Review, 28, 429435. Hollingshead, A. 6. (1975). Four factor index of social status. Unpublished manuscript. Israel, A. C., & Shapiro, L. S. (1985). Behavior problems of obese children enrolling in a weight reduction

program. Journal of Pediatric Psychology, 10, 449460. Jelliffe, D. B. (1966). The assessment of the nutritional status of the community. Genba, Switzerland: World Health

Organization. Jouriles, E. N., & Farris, A. M. (1992). Effects of marital conflict on subsequent parent-son interactions.

Behavior Therapy, 23, 355-374. Klesges, R. C., Haddock, C. K., Stein, R. J., Klesges, L. M., Eck, L. H., & Hanson, C. L. (1992). Relationship

between psychosocial functioning and body fat in preschool children: A longitudinal investigation. Journal of Consulting and Clinical Psychology, 60, 793-796.

Lerner, R. M., & Geilert, E. (1969). Body build identification, preference and aversion in children. Deuelop- mental Psychology, I, 45-62.


Maddox, G. L., Back, K. W., & Liederman, V. R. (1968). Overweight as social deviance and disability. journal

Mendelson, B. K., & White, D. R. (1982). Relation between body-esteem and self-esteem of obese and normal

Metropolitan Life Insurance Company. (1983). 1983 Metropolitan height and weight tables. Statistical Bulletin,

Phares, V., & Compas, B. E. (1992). The role of fathers in child and adolescent psychopathology: Make room

Reich, T., Van Eedewegh, P., Rice, -J., Mullaney, J., Endicott, J., & Merman, G. L. (1987). The familial

Richardson, S. A., Hastorf, A. H., Goodman, N., & Dornbusch, S. M. (1961). Cultural uniformity in reaction

Ryle, A., & Hamilton, M. (1962). Neurosis in 50 married couples. Journal ofMenta1 Science, 108, 256. Sallade, J. (1973). A comparison of psychological adjustment of obese vs. non-obese children. Journal of

Staffieri, J. R. (1967). A study of social stereotype of body image in children. Iournal of Personality and Social

of Health and Social Behavior, 9 , 287-298.

children. Perceptual and Motor Skills, 54, 899-905.

64, 1-9.

for daddy. Psychological Bulletin, 111, 387-412.

transmission of primary major depressive disorder. Journal of Psychiatric Research, 22, 613-624.

to physical disabilities. American Sociological Review, 26, 241-247.

Psychosomatic Research, 17, 89-96. ~.

Psychology, 7 , 101-104. . - Stefansson. 1. G., & Kristiansson, I. 119851. CornDanson of the General Health Questionnaire and the Cornell

Medical index health kuestionnake. Acta Psy’chiatrica Scandinavica, 72, 482487.

ciated with childhood obesity. Journal of Pediatric Psychology, 10, 337-343.

Index M-R score, and the psychogalvanic response. British journal of Psychiatry, 116, 27-32.

children. Journal of Consulting and Clinical Psychology, 52, 1104-1105.

interbehavioral model. Psychological Bulletin, 205, 116-130.

behaviors and parent adjustment. Journal of Consulting and Clinical Psychology, 56, 909-915.

Strauss, C. C . , Smith, K., Frame, C., & Forehand, R. (1985). Personal and interpersonal characteristics asso-

Verghese, A. (1970). Relationships between the Eysenck Personality Inventory N score, the Cornell Medical

Wadden, T. A., Foster, G. D., Brownell, K. D., & Finley, E. (1984). Self-concept in obese and normal-weight

Wahler, R. G., & Dumas, J. E. (1989). Attentional problems in dysfunctional mother-child interactions: An

Webster-Stratton, C. (1988). Mothers’ and fathers’ perceptions of child deviance: Roles of parent and child

child and parent factors that influence psychological problems in obese children

Documents