the effects of training parents in general child management skills on a behavioral weight loss...

BEHAVIOR THERAPY 16, 169--180 (1985)

The Effects of Training Parents in General Child Management Skills on a Behavioral Weight Loss

Program for Children

ALLEN C. ISRAEL

LAURIE STOLMAKER

CYNTHIA A. G . ANDRIAN

State University of New York at Albany

Overweight children, 8 to 12 years old, and their parents, were assigned to one of two treatment conditions or a waiting-list control. Families assigned to the Weight Reduction Only (WRO) condition received a multicomponent behavioral weight reduction program. Participants in the Parent Training (PT) condition received the same treatment preceded by a short course for the parents in general child management skills and emphasis on these skills during treatment. Children and parents in both conditions lost weight during the 8-week intensive portion of treatment, whereas control families gained weight. In addition, parental reports of improvements in children's eating habits occurred for treatment but not control children. Parents in the PT but not the WRO condition exhibited an increase in knowledge of child management skills. At 1-year follow-up, maintenance of im- proved weight status was superior for children in the PT condition and there was some indication of a relationship between child management knowledge and maintenance. A positive correlation was also obtained between changes in child and parent weight status during the follow-up period.

The potential o f behavioral interventions for the problem of childhood obesity was suggested by work with adults and by the results of early investigations with children (Brownell & Stunkard, 1978; Israel & Stol- maker, 1980). The results o f more recent programs have added to our knowledge and also provide encouragement for continued efforts (e.g., Brownell & Kaye, 1982; Epstein, Wing, Koeske, Andrasik, & Ossip, 1981;

This research was supported by Grant Number 1 RO 1 HD 13460, awarded by the National Institute of Child Health and Human Development, DHEW. The authors would like to thank Jeanette Sharp, Roxanne Ellis, Nadine Kaflowitz, Lauren Solotar, Mindy Marshall, Jodi Weinstein, and the various undergraduates for their assistance in the conduct of this research. Requests for reprints should be sent to Allen C. Israel, Psychology Department, State University of New York at Albany, 1400 Washington Avenue, Albany, NY 12222.

16 9 0005-7894/85/0169-018051.00/0 Copyright 1985 by Association for Advancement of Behavior Therapy

All rights of reproduction in any form reserved.

170 ISRAEL, STOLMAKER, AND ANDRIAN

Israel, Stolmaker, Sharp, Silverman, & Simon, 1984; Le Bow, 1984). To date, most programs have included parents in treatment. The logic for this is compelling, although too great an emphasis on parental control may not be optimal (e.g., Cohen, Gelfand, Dodd, Jensen, and Turner, 1980). A child's intake and activity patterns are, to an appreciable degree, directly regulated by his or her parents. Parental modeling is almost cer- tainly an important influence as well. Furthermore, it is impossible, if not foolhardy, to ignore the fact that parental involvement in the child's weight loss efforts is inevitable, particularly for younger children. Thus, it is likely that we will be asking parents to make changes in their own weight-related behaviors as well as in the management of their child.

Kingsley and Shapiro (1977) experimentally defined parental involvement as attendance at sessions. Their study compared the weight loss of children who attended sessions with their mother, children who attended alone and whose mothers received handouts, and children whose mothers attended sessions without them. While the mother-child group tended to do best during follow-up, there were no significant differences between groups during either treatment or follow-up. More recently, Brownell and his colleagues have demonstrated that employing separate groups for parents and adolescents produced greater weight loss and maintenance than did groups which included the mother and adolescent together or a condition in which the adolescents were seen but parents were not involved (Brownell, Kelman, & Stunkard, 1983). These findings also alert us to possible developmental aspects of parental involvement (Harris & Ferrari, 1983; Israel et al., 1984).

Epstein et al. (1981) varied contingencies to examine the question of parental involvement. They applied interventions to both parent and child weight loss, child weight loss alone, or to a nonspecific target. Again, while no overall group differences emerged, a significant correlation between parent and child weight loss during treatment was reported. In addition, there was an indication that successful children in the parent/child condition exhibited better maintenance.

Israel et al. (1984), while acknowledging the importance of parental behavior change, examined the issue of whether targeting parental weight loss was a necessary mechanism for such involvement. Parental involvement was defined either by engaging parents in a parallel weight-loss program of their own, or by specifically targeting the helping role (i.e., similar interventions aimed at improving those parental behaviors which might facilitate the child's weight loss). Both forms of parental involvement were equally successful. This suggests that it may not be necessary to have parents initiate their own weight-loss effort as a means of involving them in their child's weight-loss program.

One aspect of these behavior change efforts is not addressed by existing investigations--the parent's child management skills. In all programs, parents are called upon to participate in producing behavior change in their child. Aragona, Cassady, and Drabman (1975) compared a response cost plus reinforcement to a response cost alone weight reduction pro-

EFFECTS OF TRAINING PARENTS 171

cedure. However, parents in the first group were also provided with some training in general child management skills. An analysis of the Aragona et al. data in terms of a weight-reduction index suggests that children in the "plus reinforcement" condition exhibited better maintenance (Ed- wards, 1978). However, the small sample size (three to four children per condition), and multiple group differences suggest caution in drawing conclusions. Nevertheless, existing data are consistent with the view that attention to the child management aspect of parental participation is likely to facilitate the maintenance of weight loss. The present investigation, thus, was designed to directly evaluate the effect of explicit and additional training in general child management skills in the context of a behavioral treatment program for overweight children.

METHOD Subjects

Thirty-three children and their parents were recruited through letters to pediatricians and school nurses and advertisements in a local news- paper. All children were required to be between the ages of 8 and 12 (M = 11 years, 4 months), to be at least 20% overweight, and to obtain medical clearance from a physician. For percent overweight calculations, the assumption was made that "ideal weight" was the weight at the same percentile as the child's height. Percentiles were based on comparison with norms (Hamill, 1977) for the child's sex and age (Foreyt & Goodrick, 1981).

Assessment At an initial assessment parents completed two paper-and-pencil mea-

sures. The Eating Habit Checklist (EHC) is a 17-item parental report of the degree to which the child engages in the type of eating behavior recommended by a behavioral weight reduction program (e.g., "My child does not eat snacks while engaging in other activities," "My child keeps track carefully of what he/she eats during the day.") The EHC was designed for the present research. The Knowledge of Behavioral Principles as Ap- plied to Children (KBPAC) Scale assesses parents' knowledge of social learning principles of child management (O'Dell, Tarler-Benlolo, & Flynn, 1979). In the present investigation, the KBPAC was included to assess the initial level of this knowledge, changes with instruction in parenting skills, and retention of knowledge over the follow-up period. Measures of weight status: height, weight, and triceps skinfold, were obtained at assessment, the beginning and end of treatment, and at 1-year follow-up.

Treatment Program Therapists. All treatment sessions for parents were conducted by an

advanced graduate student in clinical psychology. Two other graduate student cotherapists assisted in conducting meetings and made between- session phone calls to assist parents with homework assignments, provide


motivational input, and further individualize the treatment procedures. The cotherapists alternated experimental conditions. Each children's group was led by two undergraduate students who were trained and supervised by the parents' group leader.

Treatment sessions and follow-up. The study was conducted in three overlapping cycles defined by time of initiation. Each cycle contained one treatment group in each experimental condition--behavioral weight reduction only (WRO), and behavioral weight reduction plus parent training (PT)--and waiting list control subjects. Participants were randomly assigned to conditions from stratified blocks based on child percent overweight and age. The WRO condition consisted of nine girls and three boys, ranging in age from 9 years, 2 months to 12 years, 1 month of age (M = 10 years, 9 months). In the PT condition, there were eight girls and four boys, with an age range from 8 years to 12 years, 11 months (M = 10 years, 7 months). The six girls and three boys in the waiting-list control condition ranged in age from 8 years, 11 months to 11 years, 9 months (M = 10 years, 5 months).

Prior to the start of the weight reduction program, parents in the PT condition attended two hour-long sessions in which they were instructed in behavioral child management skills. Lectures were based on the pre- sentation in Living With Children (Patterson, 1976). To ensure that parents had read the book and understood the main points, three brief quizzes were administered at the two initial sessions and at the first treatment session. Concepts presented during the parent training sessions were sys- tematicaUy referred to during the ensuing treatment program for PT groups only. Other than the two-sessions course and continued review of child management principles, the two groups received identical treatment.

Participants in both treatment conditions attended nine weekly 90- minute sessions of the weight reduction program. The families partici- pated in separate parent and child groups. A "four-prong" format (CAIR) was employed, in which stimulus control cues, activity (exercise), food intake (e.g., calories, nutrition), and rewards were addressed at each session and individualized for each family. Subjects were requested to mon- itor food and caloric intake, energy expenditure, and adherence to recommended changes in weight-related habits. Depending on each child's abilities, the responsibility for monitoring was divided between parent and child in such a way as to encourage the child's active participation while at the same time giving the parent ultimate responsibility for record keeping. Homework was collected and reviewed at each treatment session. Both the parents' and children's groups were conducted in a lecture- discussion format so as to provide individualized programming while also facilitating exchange of information and experiences.

After the ninth weekly session, parents and children came in for weigh- ing and brief problem-solving discussions at 1, 2, 4, 6, 9, and 12 months. During this fading period, phone calls were also gradually phased out, being made monthly after the 4-month follow-up session.

Waiting-list control subjects were seen for measurement purposes at


the beginning and end o f the weight reduct ion program. After serving as controls, they were offered t reatment in the next cycle o f the study.

O f the 30 families that started t reatment (24 original families and 6 that had initially served as control subjects), 3 dropped out before the last weekly session (Week 9). Seven more families dropped out during the follow-up period. There was no differential drop-out rate between conditions.

RESULTS Analyses o f covariance, with Week 1 measures as covariates, revealed

no differences among the three cycles (initiation time) o f treatment. Data for the analyses reported below are therefore collapsed across cycles. The data for subjects who served as waiting-list controls for one cycle and received t reatment in a subsequent cycle are considered only as control subject data for comparisons o f t reatment to control condit ions and for comparisons between the two t reatment condit ions during the t rea tment period.

Treatment Effects

Children's weight measures. Table 1 presents the unadjusted means and standard deviations for each condition. Skinfold data is not presented here or elsewhere since none o f the comparisons involving skinfold were significant. Covariance analyses, with the respective Week 1 measures as the covariates revealed significant differences at Week 9 for the pounds and percent overweight measures, F(2, 29) = 14.43, p < .001 and F(2, 29) = 15.15, p < .001, respectively. Planned comparisons o f the pounds measure indicated that the combined t reatment condit ions differed f rom controls, F(1, 29) = 31.92, p < .001, but that the two t reatment groups did not differ f rom each other. Comparable numbers of PT and W R O children (7 o f 12, and 9 o f 12, respectively) also met the criterion of 0.5 lbs. (.2 kg)/week weight loss employed to define success in program. Regarding percent overweight, W R O children had achieved a lower level at the end o f t rea tment than had PT children, and PT children were superior to controls, F(1, 29) = 6.85, p < .025; F(1, 29) = 9.15, p < .01, respectively.

Parents' weight measures. Unadjusted means and standard deviations for the parental weight measures are also presented in Table 1. Included in these analyses were those parents who were at least 15% overweight, according to the standards set forth in Bray (1974). Differences among the condit ions emerged f rom the overall covariance analysis for the parental pounds measure, F(2, 20) = 3.86, p < .04. Planned comparisons revealed a difference at Week 9, favoring the combined t reatment groups, F(1, 20) = 12.69, p < .01. However , there were no differences in weight between PT and W R O parents. Covariance analysis also revealed differences among the condit ions for the percent overweight measure (F(2, 20) = 4.65, p < 0.25), explained by the combined t reatment condit ions being less overweight at Week 9 than were the controls, F( I , 20) = 12.25, p < .01. Again, overweight PT and W R O parents did not differ. In ad-


TABLE 1 MEANS AND STANDARD DEVIATIONS FOR WEIGHT MEASURES DURING TREATMENT

Weight (kilograms/pounds)

Children Parents a

Week 1 Week 9 Week 1 Week 9

Parent training 51.75 49.55 70.85 69.06 (N = 12, 8) b 114.08 109.25 156.19 152.25

(31.58) (33.57) (54.02) (53.15) Weight reduction 57.21 54.75 78.36 76.48

only 126.13 120.71 172.75 168.61 (N= 12, 9) (19.27) (18.20) (48.37) (49.85)

Controls 58.05 59.21 72.59 73.71 (N = 9, 7) 127.97 130.53 160.04 162.50

(27.22) (27.32) (36.39) (38.28)

Percent overweight

Children Parents

Week 1 Week 9 Week 1 Week 9

Parent training 45.88 38.71 31.95 29.00 (19.77) (22.34) (41.23) (41.55)

Weight reduction 53.13 41.49 41.75 37.68 only (20.12) (22.08) (27.72) (29.16)

Controls 56.02 55.09 34.71 36.73 (16.10) (15.03) (25.27) (26.58)

Note. Numbers in parentheses are standard deviations for pounds and percent overweight. a Parents included are those who were at least 15% overweight. b N's are listed in the order children, parents.

d i t i on , t he re were no s ign i f ican t c o r r e l a t i o n s b e t w e e n p a r e n t a n d ch i ld changes in p o u n d s , p e r c e n t o v e r w e i g h t , o r s k i n f o l d d u r i n g the t r e a t m e n t pe r iod .

Ques t ionna i re measures . M e a n s a n d s t a n d a r d d e v i a t i o n s for the E H C a n d K B P A C are p r e s e n t e d in T a b l e 2. C o v a r i a n c e ana lyse s were con- duc t ed , b a s e d on the r e sponses o f al l pa ren t s . F o r b o t h the E H C a n d K B P A C the re were d i f fe rences a m o n g the t h ree c o n d i t i o n s a t W e e k 9 (F(2, 28) = 38.87, p < .01; F(2 , 29) = 16.31, p < .001, r e spec t ive ly ) . O n the E H C , the c o m b i n e d t r e a t m e n t g roups h a d h ighe r (bet ter ) scores t h a n c o n t r o l s a t W e e k 9 (F(1, 28) -- 84 .85, p < .001), b u t the t r e a t m e n t g roups d i d n o t differ f r o m each o ther . T h e l ack o f change in the E H C scores o f c o n t r o l sub jec t s suggests t h a t t he m e a s u r e is r e l i ab le o v e r t ime . R e g a r d i n g K B P A C differences , the P T p a r e n t s s co red h ighe r (be t te r ) t h a n d i d the W R O p a r e n t s (F(1, 29) = 17.70, p < .001), a n d the W R O p a r e n t s d i d no t differ f r o m cont ro ls . N o n e o f the co r re l a t ions be tw e e n E H C a n d K B P A C scores ( W e e k 1 o r W e e k 9) a n d changes in we igh t m e a s u r e s d u r i n g the t r e a t m e n t p e r i o d r e a c h e d s ignif icance.


TABLE 2 MEANS AND STANDARD DEVIATIONS FOR THE EHC AND KBPAC DURING TREATMENT

EHC

Week 1 Week 9

Parent training 14.75 25.50 (N= 12) (3.77) (3.99)

Weight reduction 12.18 25.27 only (3.06) (2.20) (N= 11)

Controls 12.67 13.22 (N = 9) (3.50) (4.47)

KBPAC

Week 1 Week 9

Parent training 18.67 32.92 (N= 12) (6.68) (8.43)

Weight reduction 20.92 26.08 only (9.44) (9.6 l) (N = 12)

Controls 20.67 23.22 (N = 9) (5.72) (7.56)

Note. Numbers in parentheses are standard deviations.

Follow-up Effects All analyses for the fol low-up period were two-group (PT, W R O ) re-

peated measures (Week 9, 1-year follow-up) analyses o f covariance, with Week 1 measures as covariates. Since subjects who served as waiting-list controls for the t rea tment per iod were then offered t rea tment , no control group was available for the fol low-up period. The n u m b e r of subjects in fol low-up analyses differs f rom those repor ted for the t rea tment per iod for two reasons. Subject at tr i t ion during the fol low-up per iod accounts in par t for this difference. In addit ion, previous control subjects were assigned to their respective t rea tment condit ions for fol low-up per iod analyses only.

Children's weight measures. Table 3 presents unadjusted means and s tandard deviat ions for those subjects who at tended the 1-year follow- up. Both t rea tment condit ions gained weight over the fol low-up period (F(1, 18) = 36.53, p < .001), with no differences in gains between the groups. However , since these children were in a per iod o f expected growth, the percent overweight measure is p robab ly a bet ter index o f change in weight status.

For percent overweight, there was an interact ion between t rea tment condi t ion and t ime o f measurement , F(1, 18) = 4.65, p < .045. Whereas PT children had nonsignificant decreases in percent overweight during

176 ISRAEL~ STOLMAKER, AND ANDRIAN

TABLE 3 MEANS AND STANDARD DEVIATIONS FOR FOLLOW-UP SUBJECTS' WEIGHT MEASURES

Weight (kilograms/pounds)

Children Parents a

Week 1 b Week 9 1 Year Week 1 Week 9 1 Year

Parent training 51.22 49.07 56.42 87.45 85.07 82.98 (N= 11, 5)" 112.93 1 0 8 . 1 8 1 2 4 . 3 9 192.80 1 8 7 . 5 5 182.95

(34.22) (36.14) (47.38) (51.17) (51.99) (49.45) Weight reduction 55.16 52.39 60.43 71.29 69.98 70.82

only 121.61 115.50 1 3 3 . 2 2 1 5 7 . 1 7 1 5 4 . 2 9 156.13 (N = 9, 6) (14.95) (15.01) (19.31) (17.27) (21.06) (26.15)

Percent overweight

Children Parents

Week 1 Week 9 1 Year Week 1 Week 9 1 Year

Parent training 50.60 43.40 40.40 48.67 44.88 42.92 (17.48) (21.63) (32.86) (45.81) (47.05) (42.67)

Weight reduction 46.82 33.61 45.53 36.48 33.91 35.62 only (15.57) (16.99) (21.21) (11.35) (14.46) (17.88)

Height (centimeters/inches)

Children

Week 1 Week 9 1 Year

Parent training 139.75 1 4 0 . 1 1 145.00 55.02 55.16 57.48 (3.42) (3.48) (3.34)

Weight reduction 145.34 1 4 6 . 4 8 151.49 only 57.22 57.67 59.64

(2.21) (2.09) (1.89)

Note. Numbers in parentheses are standard deviations for pounds, percent overweight, and inches.

a Parents included are those who were at least 15% overweight. b Week 1 measures are included and differ from those in Table 1 because of the inclusion of former controls in the appropriate treatment groups and since subject attrition occurred during follow-up. c N's are listed in the order children, parents.

fo l low-up, the W R O ch i ld ren increased on this measure , (F(1, 18) = 32.36, p < .001. These resul ts suppor t the i m p o r t a n c e o f e m p l o y i n g a re la t ive (percent overweight) ra ther t h a n a n abso lu te (lbs.) i ndex o f change over ex tended per iods o f t ime. These g roup differences in pe rcen t overweigh t are cons i s t en t wi th the f ind ing tha t in the year pe r iod f rom the e nd o f t r e a t m e n t to fol low-up, 8 o f 1 1 P T ch i ld ren m a i n t a i n e d or decreased the i r


TABLE 4 MEANS AND STANDARD DEVIATIONS FOR THE EI-IC AND KBPAC DURING FOLLOW-UP

EHC

Week 1 a Week 9 1 Year

Parent training 13.63 24.00 19.50 (N = 8) (3.78) (4.90) (4.78)

Weight reduction 12.22 25.22 16.67 only (N = 9) (2.95) (1.86) (5.48)

KBPAC

Week 1 Week 9 1 Year

Parent training 21.50 36.75 34.63 (6.09) (5.04) (8.85)

Weight reduction 25.75 30.50 31.00 only (9.75) (7.17) (9.20)

Note. Numbers in parentheses are standard deviations. "Week 1 measures are included and differ from those in Table 2 because of the inclusion of former controls in the appropriate treatment groups, subject attrition, and missing data.

percent overweight, whereas only 2 o f 9 W R O children exhibited this pattern. In addition, 4 o f 11 PT children, but only 1 o f 9 W R O children, reached nonobese status.

Parents' weight measures. Unadjusted means and standard deviations for the parental weight measures through the 1-year follow-up are presented in Table 3. Again, only overweight parents ' data were analyzed. There were no differences between the treatment conditions or between the Week 9 and 1-year measurement points. A significant relationship existed, however, between overweight parents ' and children's respective changes in percent overweight during this period, r(10) = .82, p < .002.

Questionnaire measures. Table 4 presents the unadjusted means and standard deviations for follow-up subjects' scores on the EHC and KBPAC. Scores on the EHC went down over the follow-up period for both treatment conditions (F(1, 15) = 20.82, p < .001), with no differences between the PT and W R O groups. Overall, EHC scores at Week 9 and 1-year were not related to changes in any of the children's weight measures over the same period o f time.

Although overall changes in EHC scores and weight status were not related, the difference between EHC scores at 1-year follow-up of children who achieved nonobese status versus those who were successful during t reatment but did not achieve nonobese status during the follow-up period was significant, t ( l l ) = 1.92, p < .05. Parents of those children who achieved nonobese status reported better eating habits for their children.

On the KBPAC, the PT parents maintained their higher scores over


the follow-up period relative to the WRO parents, F(1, 13) = 10.99, p < .006. KBPAC scores at Week 9 and 1-year were marginally related to changes in children's weights from Week 1 to 1-year (r(15) = .43, p < .06), with higher scores associated with lesser weight gain.

DISCUSSION The importance of addressing parental behavior change in the process

of treating childhood obesity is supported by the current results. In the present study, prior instruction in general child management skills, which was then integrated into the remainder of the treatment program, produced increases in parental knowledge and superior maintenance of im- proved weight status. A weight-reduction program which did ask parents to assist in changing their child's behavior, but did not provide as explicit training, failed to produce changes in parental knowledge greater than that achieved by parents receiving no treatment. The more consistent and superior maintenance of change in weight status among children whose parents received explicit training suggests that such knowledge was trans- lated into action. The finding that parent's acquisition of this knowledge, as assessed at year follow-up, was to some degree related to greater success provides further support for this notion. However, since the present study did not evaluate actual changes in child management behavior, it remains to determine what specific changes in parental behavior were responsible for the greater degree of success achieved.

It should also be noted that changes in percent overweight were greater for the WRO group at the end of the intensive treatment period and that the superiority of the PT condition was achieved during the following year period. This suggests that the impact of training parents in child management occurs during this period of reduced contact with the program. The relationship between parent and child weight during this period adds additional impact to this finding and to the importance of providing parents with skills to sustain their child's progress.

Apart from the indicated importance of parents as change agents, a number of the current findings are also informative. The present results, consistent with the findings of other investigators, seem encouraging regarding the treatment of childhood obesity. However, as always, enthu- siasm should be tempered with caution. While about three-fourths of the children in the PT condition maintained or decreased their percent overweight during the follow-up period, only about one-third of the children achieved nonobese status. These findings are encouraging in that main- taining weight over some period of time will, because of growth, result in nonobese status (Dietz, 1983). However, they also indicate that procedures that result in even greater weight loss and ability to sustain change are needed for at least some children and families.

Finally, the current results indicate that both treatments were successful in changing the eating habits of these children, at least as indicated by parental report. However, it would also appear that better maintenance of such habit change needs to be achieved. Although no overall relation-


sh ip b e t w e e n the E H C m e a s u r e a n d success in p r o g r a m was found , the re is the sugges t ion t ha t the h a b i t s o f the m o s t successful c h i l d r e n d i d change. F u r t h e r m o r e , the n a t u r e a n d l i m i t a t i o n s o f the c u r r e n t p a r e n t a l r e p o r t m e a s u r e o f ea t ing h a b i t s a l so m i t i g a t e s aga ins t the j u d g m e n t t ha t no r e l a t i o n s h i p exis t s b e t w e e n changes in ea t ing h a b i t s a n d we igh t loss. In- deed , logic, o u r o w n resul ts , a n d the a d u l t l i t e r a tu re (e.g., S a n d i f e r & B u c h a n a n , 1983) a rgue aga ins t such a conc lus ion .

M o s t ex is t ing p r o g r a m s i m p l i c i t l y re ly on the p a r e n t as a change agent , ye t few d i r ec t l y a d d r e s s th is role. T h e p r e s e n t resu l t s r ega rd ing ch i ld m a n a g e m e n t ski l ls a n d o t h e r f ind ings (e.g., B r o w n e l l e t al. , 1983; C o h e n et al . , 1980; Eps t e in et al . , 1981; I s rae l e t al. , 1984) c lea r ly a rgue for c o n t i n u e d a t t e n t i o n to t he m u l t i p l e p a r e n t a l b e h a v i o r s t ha t m a y p o t e n - t i a l ly in f luence a c h i l d ' s we igh t loss efforts.

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Patterson, G. R. (1976). Living with children: New methods for parents and teachers (3rd ed.). Champaign, IL: Research Press.

Sandifer, B. A. & Buchanan, W. L. (1983). Relationship between adherence and weight loss in a behavioral weight reduction program. Behavior Therapy, 14, 682-688.

RECEIVED" February 21, 1984 FINAL ACCEPTANCE" June 4, 1984

the effects of training parents in general child management skills on a behavioral weight loss...

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