Psychological Adjustment of Obese Youth ... - Wiley Online Library

See Commentary by Tershakovec on pages 1537–1538

Psychological Adjustment of Obese Youth Presenting for Weight Management Treatment Meg H. Zeller, Brian E. Saelens, Helmut Roehrig, Shelley Kirk, and Stephen R. Daniels

Abstract ZELLER, MEG H., BRIAN E. SAELENS, HELMUT ROEHRIG, SHELLEY KIRK, AND STEPHEN R. DANIELS. Psychological adjustment of obese youth presenting for weight management treatment. Obes Res. 2004;12:1576 –1586. Objective: To determine the prevalence of psychological maladjustment in clinic-based treatment-seeking obese children and adolescents (BMI ⱖ 95th percentile) and the degree to which maternal, demographic, and youth factors correlate to the youths’ psychological adjustment. Research Methods and Procedures: Anthropometrics, demographics (race, sex, insurance status), measures of youth psychological adjustment (self- and mother-report; Behavior Assessment System for Children), and maternal selfreport of psychological distress (Symptom Checklist 90Revised) were collected from 121 obese children and adolescents (55% white, 45% black) and their mothers. Results: Approximately one-third of youths self-reported some psychological maladjustment, but two-thirds of youth were described by their mothers as experiencing some degree of psychological maladjustment. Adjustment difficulties were specific to social functioning, low self-esteem, and internalizing symptoms. Forty-one percent of mothers of child participants and 56% of mothers of adolescent participants reported clinically significant psychological distress. Youth self-report and mother-report of youths’ psychological difficulties were often most strongly associated with mothers’ level of psychological distress and/or family socioeconomic status rather than to youth characteristics (e.g., percent overweight, race). Discussion: Psychological maladjustment levels among

Received for review November 3, 2003. Accepted in final form August 2, 2004. The costs of publication of this article were defrayed, in part, by the payment of page charges. This article must, therefore, be hereby marked “advertisement” in accordance with 18 U.S.C. Section 1734 solely to indicate this fact. Cincinnati Children’s Hospital Medical Center, University of Cincinnati College of Medicine, Cincinnati, Ohio. Address correspondence to Meg Zeller, Division of Psychology, ML D-3015, Cincinnati Children’s Hospital Medical Center, 3333 Burnet Avenue, Cincinnati, OH 45229. E-mail: [email protected] Copyright © 2004 NAASO

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obese youth and their mothers were higher in this clinicbased sample than in treatment research-based samples. Present correlate findings extended to obese adolescents and reaffirm a potent association between youth self-report of their own psychological adjustment and their mother’s level of psychological distress. Demographic characteristics and youth weight status were not consistent correlates of youths’ psychological functioning. Findings have implications for the translation of empirically supported pediatric obesity interventions to clinic-based treatment samples. Key words: psychopathology, adolescence, blacks, Medicaid

Introduction Increasingly prevalent childhood obesity is a growing public health concern (1) associated with both physical (2) and psychological (3) health consequences. However, poor psychological adjustment is not universal for obese children (4). Evidence has suggested that social and internalizing problems (e.g., depression, body image concerns) may be more common than externalizing (e.g., aggression) problems among these children. For instance, parents of obese children seeking weight treatment for their children have reported that their children exhibit greater social withdrawal and somatic complaints and lower social competence, with average scores often equivalent to values of children being seen in mental health clinics (5,6). Braet et al. (7) have found that obese children seeking treatment had higher rates of overall internalizing and externalizing difficulties, specifically with lower social competence than both non–treatment-seeking obese children and nonobese children. In that study, obese children seeking treatment were more likely to be at or above the threshold level of clinically significant impaired psychological functioning (20%) compared with non–treatment-seeking obese (4%) or nonobese children (3%). There has been considerable focus on whether the level of children’s overweight is related to children’s psychological health status (7). However, evidence generally has suggested that parent psychopathology accounts for significant

Psychological Adjustment of Obese Youth, Zeller et al.

variance in their child’s psychological functioning, with no evidence that child’s level of overweight contributes independently to the prediction of child psychological functioning (8,9). Limitations to prior research have included that, with few exceptions, these studies have been conducted among samples of children and families who are racially, economically, and psychologically homogeneous, because past samples were often enrolled in treatment research trials for pediatric obesity. Efficacy treatment trials rely on volunteerism for participation and often require children and parents to meet strict exclusion criteria including, for example, that no family member is undergoing psychiatric treatment (10). Furthermore, such samples may not be demographically representative of the population of overweight children or the children presenting for clinic-based weight control treatment. Only a few researchers have included an adequate sampling of ethnic minority populations (5,11), with the majority of data generated from middle to upper middle class white families (12). In addition, prior research examining psychological functioning among overweight children has been limited to children ⬍12 years old, preventing exploration of developmental trends in overweight children’s psychological functioning. Obese adolescents may present with unique psychological issues that dictate a different model of treatment than for younger children. The level of overweight in adolescence may be related to adolescents’ psychological functioning above and beyond parental psychopathology because of increasing stigma and weight criticism with child age and greater emphasis on body image and ideals in adolescence (13). Prior research has also relied primarily on mother-report of child psychological functioning. Reliance on mother-report may be problematic given that the data documenting maternal distress may be an important correlate of child adjustment difficulties for obese youth (8,9), and that the data suggest, for youth in general, that mother-report on child adjustment may be biased by maternal distress (14,15). The purpose of this study was to determine the prevalence of psychological maladjustment, assessed by both child- and parent-report, in obese children and adolescents seeking treatment at an outpatient pediatric weight control clinic. It was hypothesized that rates of clinically significant social and internalizing problems would be higher than in prior studies examining obese children enrolled in treatment research trials and would differ between children and adolescents. The degree to which a mother’s level of psychological distress was an additional correlate of child/adolescent psychological adjustment was also examined. It was hypothesized that mother’s psychological distress would be related to child and adolescent psychological adjustment, but that child, and particularly adolescent, degree of overweight would be an independent predictor of children’s psychological adjustment. Finally, the contribution of so-

cioeconomic status (SES)1 to youth outcomes was examined. The hypothesis that SES would account for variance of child or adolescent psychological adjustment beyond that of maternal distress was presented.

Research Methods and Procedures Participants and Procedures Participants were children and adolescents and their mothers enrolling in a pediatric interdisciplinary weight management clinic. Clinic eligibility criteria included physician referral and a BMI (kilograms per meter squared) above the 95th percentile for age- and sex-based national norms from the Centers for Disease Control (16). Based on a retrospective chart review, of the 175 patients consecutively enrolled in the clinic from April 1999 to March 2001 who met age inclusion criteria (age, 8 to 17 years), complete data (i.e., all three psychological measures) were obtained from 79% (N ⫽ 138). Given the specific interest in mother’s perspective of her child’s, as well as her own, psychological health, patients were excluded from analysis if the primary caregiver who completed the clinic assessments was either a father, other relative, or state-appointed legal guardian (n ⫽ 17). Data were collected as part of the family’s comprehensive intake evaluation that included physiological, anthropometric, nutritional, and psychological assessment. Approval for analysis of these clinical data was obtained from the Institutional Review Board of Cincinnati Children’s Hospital Medical Center. The final sample included 121 children (46 boys and 75 girls; mean age, 12.3 years) of whom 54.5% were white and 45.4% were black. Given the small percentage (2.7%) of other racial/ethnic groups, these children/adolescents were not included. Forty-six percent of families had private insurance or were self-paying, with the remainder being Medicaid recipients. This final sample (n ⫽ 121) did not differ by race, sex, age, insurance status, or degree of overweight from those participants who were excluded from analyses. The final sample was grouped by age into children (ages 8 to 11 years; N ⫽ 62) and adolescents (ages 12 to 17 years; N ⫽ 59) to match age groupings of the normative samples of the psychological measures. Measures Demographic Information. Demographic information including race and type of insurance was obtained from the participants’ medical records. Anthropometric Measures. Youth participants’ body weights were recorded using a digital scale, and heights were measured using a calibrated wall-mounted stadiom-

1 Nonstandard abbreviations: SES, socioeconomic status; zBMI, standardized BMI; BASC, Behavior Assessment System for Children; SRP, self-report measure; PRS, parent rating scale; SCL-90-R, Symptom Checklist 90-Revised; GSI, Global Severity Index.


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eter. Children were weighed and measured in light clothing and without shoes. BMI values were calculated (kilograms per meter squared) and standardized (zBMI) using an age- (to the nearest month) and sex-specific median, SD, and power of the Box-Cox transformation (LMS method) based on national norms from the Centers for Disease Control (16). Details regarding the calculation of zBMI using the LMS method are available at www.cdc.gov/nchs/ about/major/nhanes/growthcharts/datafiles.htm. Mother’s BMI was calculated based on the self-reported body weight and height recorded on the weight management program intake form. Epidemiological data (National Health and Nutrition Examination Study III) have shown that selfreported heights and weights are highly correlated with measured heights and weights (r ⫽ 0.89 to 0.97) in a nationally representative sample of adults 20 to 60 years of age (17). Behavior Assessment System for Children. The Behavior Assessment System for Children (BASC) (18) was used to measure both positive (adaptive) and negative (clinical) dimensions of child and adolescent psychological adjustment. The BASC includes a self-report measure (SRP) and parent-rating scale (PRS). The SRP and PRS each have forms at two age levels, child (ages 8 to 11 years; SRP-C and PRS-C) and adolescent (ages 12 to 18 years; SRP-A and PRS-A), with substantial overlap but minor variation in item content across the two age levels. The SRP and PRS were interpreted with reference to national age norms, with standardization samples consistently matching U.S. population percentages of racial/ethnic groups. T scores (50 ⫾ 10) indicate the distance of composite and scale scores from a norm-group mean. T scores in the “at-risk” range (clinical composites/scales: 60 ⱕ T score ⱕ 69; adaptive composites/scales: 31 ⱕ T score ⱕ 40) indicate significant problems that require close monitoring and/or intervention. Scores in the clinically significant range (clinical composites/scales: T score ⱖ 70; adaptive composites/scales: T score ⱕ 30) indicate a pattern of significantly maladaptive behavior. T scores ranging from 41 to 59 are considered average. For the purposes of this study, the “at-risk” and “clinically significant” categories were combined to denote the prevalence of problematic behaviors or self-perceptions outside of the average range. The SRP includes 186 “True” or “False” statements at both age levels that render three composite scores, School Maladjustment, Clinical Maladjustment, and Personal Adjustment, based on 12 scales of the SRP-C and 2 additional scales of the SRP-A. The SRP shows adequate internal consistency (␣, 0.86 to 0.96), satisfactory test-retest reliability, and convergent validity with other self-report measures of child (19) and adolescent (20) psychological adjustment. In this study, multivariate analyses focused on the six specific scale scores that assessed self-perceptions of social functioning (i.e., interpersonal relations, social stress, rela1578


tions with parents), internalizing symptoms (i.e., depression and anxiety), and self-esteem. The PRS contains 126 descriptors of adaptive and problem behaviors that parents rate on a four-point scale from “Never” to “Almost Always.” The PRS-C and PRS-A have three identical composite scores, Internalizing Problems, Externalizing Problems, and Adaptive Skills, based on the 15 scales of the PRS-C and 14 scales of the PRS-A. The PRS shows adequate internal consistency (␣, 0.85 to 0.93), satisfactory test-retest reliability, and convergent validity with the commonly used parent-report measure—the Child Behavior Checklist (20). In this study, PRS multivariate analyses focused on the three composite scores that assessed internalizing problems (i.e., anxiety, depression, somatization), externalizing problems (i.e., aggression, hyperactivity, conduct), and adaptive skills (i.e., social skills, leadership, adaptability). Symptom Checklist 90-Revised (SCL-90-R). The SCL90-R (21) is a 90-item instrument that measures adults’ current psychological symptom status. Symptoms are classified into nine dimensions of symptomatology and three global indices. The SCL-90-R demonstrates adequate internal consistency (␣’s range from .77 to .90) and satisfactory test-retest reliability (21). The Global Severity Index (GSI) combines information on the number of symptoms reported and their intensity, and is considered the best single summary measure of symptomatology. In the present study, the GSI T score (mean ⫽ 50, SD ⫽ 10) indicates the distance from the national age norm-group mean. In addition, for the purposes of comparison with previous research (8,9), meeting clinical criteria for “caseness,” which is defined as a T score ⱖ63 on the GSI or on any two of the nine dimension scores of the measure, was also calculated for each participant. Data Analyses Mean T scores and SD for all BASC PRS and SRP scales were calculated, as were the rates that children and adolescents scored in the at-risk/clinical range. Normal approximation to the binomial tests compared the observed frequencies of at-risk/clinical range scale scores to the population base-rate, based on instrument norms, with ␣ set at 0.0001 to account for multiple comparisons. Zero-order correlations were calculated between all variables within each age group. Hierarchical regression analyses assessed the impact of child/adolescent race (Step 1), child/adolescent degree of overweight (zBMI) (Step 2), mother’s level of psychological distress (GSI) (Step 3), and insurance status (Step 4) on the T scores of six specific child/adolescent scales that assessed self-perceptions of social functioning (i.e., Interpersonal Relations, Social Stress, Relations With Parents), internalizing symptoms (i.e., Depression and Anxiety), and Self-Esteem and the three BASC PRS composites (i.e., Internalizing, Externalizing, and Adaptive


Table 1. Child and adolescent BASC-SRP (self-report) mean T scores and standard deviations and percent of participants whose T scores fell within an at-risk/clinically significant range Children (n ⴝ 62) Measure: BASC-SRP Clinical scales Attitude to school Attitude to teachers Sensation seeking Atypicality Locus of control Somatization Social stress Anxiety Depression Sense of inadequacy Adaptive scales Relations with parents Interpersonal relations Self-esteem Self-reliance Composite scores School maladjustment Clinical maladjustment Personal adjustment

Adolescents (n ⴝ 59)

Mean ⴞ SD

At-risk/Clinical (n)

Mean ⴞ SD


47.0 ⫾ 9.9 48.1 ⫾ 10.2 NA 45.5 ⫾ 9.9 47.3 ⫾ 9.0 NA 49.5 ⫾ 10.1 49.2 ⫾ 10.3 48.3 ⫾ 9.3 50.6 ⫾ 11.4

11.3% (7) 16.2% (10) NA 11.5% (7) 8.0% (5) NA 22.6% (14) 22.6% (14) 14.5% (9) 17.8% (11)

50.6 ⫾ 11.4 51.5 ⫾ 10.2 47.1 ⫾ 9.4 50.2 ⫾ 10.4 52.6 ⫾ 11.1 56.6 ⫾ 9.4 52.0 ⫾ 11.2 50.5 ⫾ 9.6 52.8 ⫾ 11.9 52.1 ⫾ 10.5

23.8% (14) 23.7% (14) 10.2% (6) 18.7% (11) 30.5% (18) 38.9% (23) 25.5% (15) 18.6% (11) 25.5% (15)* 23.8% (14)

51.2 ⫾ 9.8 46.7 ⫾ 12.7 48.4 ⫾ 11.1 51.3 ⫾ 9.0

14.5% (9) 24.2% (15) 25.8% (16) 11.3% (7)

48.8 ⫾ 10.9 49.5 ⫾ 11.6 44.0 ⫾ 11.7 51.6 ⫾ 8.0

22.1% (13) 13.6% (8) 40.6% (24)* 15.3% (9)

47.3 ⫾ 10.5 47.6 ⫾ 9.6 49.3 ⫾ 11.1

16.1% (10) 14.5% (9) 17.8% (11)

49.7 ⫾ 10.3 52.9 ⫾ 9.9 48.0 ⫾ 10.3

17.0% (10) 23.8% (14) 25.4% (15)

* p ⬍ .0001 significant difference between observed base rates of at-risk/clinical scores and population base rates based on published norms. At risk/clinical criteria for above measures were based on the instrument norm interpretive guidelines (BASC-SRP: clinical scales T score ⱖ 60; adaptive scales T score ⱕ 40; school maladjustment T score ⱖ 60; clinical maladjustment ⱖ 60; personal adjustment ⱕ 40). Sensation Seeking and Somatization clinical subscales are unique to the adolescent SRP. NA, not applicable.

Skills). Data analyses were completed using SPSS, Version 11.5, SPSS, Inc., Chicago, IL.

Results Degree of Obesity zBMI. All youth participants met and/or exceeded clinical criteria for pediatric obesity (BMI ⱖ 95th percentile for age and sex), and a considerable number (15% of children and 53% adolescents) met adult criteria for severe obesity (BMI ⱖ 40 kg/m2). Adolescent mean zBMI was significantly higher than child mean zBMI (2.62 vs. 2.49 kg/m2, respectively; p ⬍ 0.05). Black children had higher average zBMI than white children (2.57 vs. 2.43 kg/m2, respectively; p ⬍ 0.05). There were no significant differences for adolescent zBMI based on race, and there were no child or adolescent zBMI differences based on sex or insurance.

Maternal BMI. One hundred four of the mothers (86%) provided self-report of their own height and weight in the medical chart, whereas 14% omitted responses to these items on the intake forms. The mean BMI was 34.9 ⫾ 10.9 (SD) kg/m2; 19.2% (n ⫽ 20) were of normal weight (18.5 ⱕ BMI ⱕ 24.9 kg/m2), 16.3% (n ⫽ 17) were in the overweight range (25 ⱕ BMI ⱕ 29.9 kg/m2), 38.5% (n ⫽ 40) were in the obese range (30 ⱕ BMI ⱕ 39.9 kg/m2), and 26% (n ⫽ 27) met criteria for severe obesity (BMI ⱖ 40 kg/m2). Prevalence of Psychological Maladjustment Child and Adolescent Self-Report of Psychological Functioning. Mean T scores on the BASC-SRP for child and adolescent self-report of psychological adjustment were within the average range (Table 1). There were no significant differences in mean T scores between adolescent and child participants. Based on having at least one T composite OBESITY RESEARCH Vol. 12 No. 10 October 2004

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Table 2. Child and adolescent BASC-PRS (mother-report) mean T scores and SD and percent of participants whose T scores fell within an at-risk/clinically significant range Children (n ⴝ 62) Measure: BASC-PRS Clinical scales Hyperactivity Aggression Conduct problems Anxiety Depression Somatization Atypicality Withdrawal Attention problems Adaptive scales Adaptability Social skills Leadership Composite scores Externalizing problems Internalizing problems Adaptive skills

Adolescents (n ⴝ 59)

Mean ⴞ SD


Mean ⴞ SD


50.1 ⫾ 13.8 52.5 ⫾ 13.2 53.8 ⫾ 11.6 54.5 ⫾ 12.5 62.2 ⫾ 18.5 61.1 ⫾ 15.0 54.3 ⫾ 15.5 56.9 ⫾ 12.4 56.1 ⫾ 12.3

22.6% (14) 27.4% (17) 29.1% (18) 29.0% (18) 46.8% (29)* 48.4% (30)* 27.4% (17) 38.7% (24)* 38.7% (24)*

53.5 ⫾ 14.1 57.0 ⫾ 16.7 55.7 ⫾ 17.4 57.1 ⫾ 14.3 62.4 ⫾ 15.5 61.1 ⫾ 14.6 52.8 ⫾ 12.1 61.9 ⫾ 17.7 55.7 ⫾ 14.3

32.2% (19)* 37.2% (22)* 28.9% (17) 37.3% (22)* 55.9% (33)* 54.2% (32)* 20.4% (12) 50.8% (30)* 37.2% (22)*

42.0 ⫾ 11.2 45.2 ⫾ 10.4 44.0 ⫾ 9.2

40.3% (25)* 37.1% (23)* 32.3% (20)

NA 44.2 ⫾ 9.7 43.6 ⫾ 9.5

NA 33.9% (20)* 32.2% (19)

52.4 ⫾ 12.9 62.1 ⫾ 16.6 42.7 ⫾ 10.4

21.0% (13) 51.6% (32) 45.2% (28)

56.4 ⫾ 16.8 62.0 ⫾ 14.9 43.2 ⫾ 9.6

35.6% (21) 54.2% (32) 37.3% (22)

* p ⬍ .0001 significant difference between observed base rates of at-risk/clinical scores and population base rates based on published norms. At risk/clinical criteria for above measures were based on the instrument norm interpretive guidelines (BASC-PRS: clinical scales T score ⱖ 60; adaptive scales T score ⱕ 40; externalizing problems T score ⱖ 60; internalizing problems T score ⱖ 60; adaptive skills T score ⱕ 40). Adaptability is a unique subscale to the child PRS. NA, not applicable.

score (i.e., School Maladjustment, Clinical Maladjustment, and/or Personal Adjustment) falling within the at-risk/clinical range, ⬃29% of obese children and 37% of obese adolescents self-reported some degree of psychological maladjustment. Observed frequencies of at-risk/clinical range SRP scale scores were not significantly different from population base rates with the exception of adolescent self-report of greater Somatization and lower SelfEsteem (Table 1). Parent-Report of Child/Adolescent Functioning. Mean T scores on the BASC-PRS for mother-report of child and adolescent Depression, Somatization, and the Internalizing Problems composite, as well as adolescent Withdrawal, were within the “at risk” range (Table 2). All other child and adolescent BASC-PRS scores and composites were within the average range. There were no significant differences in mean T scores between adolescent and child participants. Based on having at least one T composite score (i.e., Internalizing, Externalizing, Adaptive Skills) falling within the 1580


at-risk/clinical range, ⬃66% of obese children and 69% of obese adolescents were described by mothers as experiencing some degree of psychological maladjustment. Observed frequencies of at-risk/clinical range PRS scale scores were significantly greater than population base rates for motherreport of child and adolescent Depression, Somatization, Withdrawal, and impaired Social Skills, as well as several additional adolescent scales (Table 2). Maternal Self-Report of Psychological Distress. The mean GSI T scores on the SCL-90-R for mother’s selfreport of their own psychological distress were within the average range for mothers of both children (58.2 ⫾ 9.9) and adolescents (59.1 ⫾ 9.3) in the present sample. However, 41% (n ⫽ 26) of mothers of child participants and 56% (n ⫽ 33) of mothers of adolescent participants exceeded the clinical cut-off of caseness for significant psychological distress.


Table 3. Zero-order intercorrelations for BASC-SRP (self-report), BASC-PRS (mother-report) demographic variables, child zBMI, maternal distress, and maternal BMI for children (n ⫽ 62; age, 8 to 11 years)

1. 2. 3. 4. 5. 6. 7. 8. 9. 10. 11. 12. 13. 14. 15.

Insurance Gender Race Child zBMI Social stress§ Anxiety§ Depression§ Relations with parents§** Interpersonal relations§ Self-esteem§ Adaptive skills¶** Internalizing¶ Externalizing¶ Maternal distress (GSI) Maternal BMI††

1

2

3

4

5

6

7

8

9

10

⫺.10 ⫺.63‡ .04 ⫺.07 ⫺.02 ⫺.19 .15 .19 ⫺.09 .45‡ ⫺.28* ⫺.39† ⫺.30* ⫺.41†

.20 .16 ⫺.10 .05 ⫺.15 .21 .10 .19 .16 ⫺.06 ⫺.21 ⫺.30 .17

.27* ⫺.04 .04 .09 .03 ⫺.01 .11 ⫺.30* ⫺.03 .12 .13 .36†

⫺.05 ⫺.02 ⫺.04 ⫺.02 ⫺.08 .20 ⫺.18 ⫺.24 ⫺.04 ⫺.05 .09

.77‡ .73‡ ⫺.35‡ ⫺.73‡ ⫺.57‡ ⫺.31* .55‡ .54‡ .35† .25

.60‡ ⫺.09 ⫺.49‡ ⫺.42‡ ⫺.21 .47‡ .48‡ .20 .20

⫺.59‡ ⫺.77‡ ⫺.65‡ ⫺.38† .61‡ .57‡ .49‡ .26

.55‡ .55‡ .41† ⫺.36† ⫺.39† ⫺.37† ⫺.27

.56‡ .34† ⫺.52‡ ⫺.38† ⫺.35† ⫺.16

.17 ⫺.42† ⫺.32* ⫺.28* ⫺.28*

11

12

13 14 15

⫺.38† ⫺.46‡ .65‡ ⫺.34† .40† .36† ⫺.38‡ .16 .38† .21

* p ⬍ .05; † p ⬍ .01, ‡ p ⬍ .001. § BASC-SRP (child self-report). ¶ BASC-PRS (mother-report). ** Low scores indicate less desirable characteristics. †† Intercorrelations with maternal BMI are based on a smaller sample (n ⫽ 51 children).

Intercorrelations Intercorrelations of the six BASC-SRP scale scores, the BASC-PRS composites scores, GSI, zBMI, and demographic variables are presented in Tables 3 and 4. Also included are the intercorrelations of these variables with maternal BMI in the somewhat smaller sample. Of note, maternal BMI was unrelated to level of psychological distress (GSI) for both children and adolescents. Multivariate Analyses Prediction of SRP Child. As presented by the regression model summary in Table 5, greater maternal psychological distress was the only significant predictor of child self-reported distress in parent-child relations (standardized ␤-coefficient, ␤ ⫽ ⫺0.35; p ⬍ 0.01), higher social stress (␤ ⫽ 0.35; p ⬍ 0.01), lower self-esteem (␤ ⫽ ⫺0.33; p ⬍ 0.05), lower interpersonal relations with peers (␤ ⫽ ⫺0.32; p ⬍ 0.05), and greater depressive symptomatology (␤ ⫽ 0.47; p ⬍ 0.001). There were no significant predictors of child self-report of anxiety symptoms. Race and degree of child overweight were not significant predictors in any model of child selfreport of psychological adjustment. Adolescent. As summarized in Table 5, greater maternal psychological distress was the only significant predictor of

adolescent self-reported higher social stress (␤ ⫽ 0.40; p ⬍ 0.01) and greater depressive symptomatology (␤ ⫽ 0.32; p ⬍ 0.05). Both maternal distress (␤ ⫽ ⫺0.38; p ⬍ 0.01) and race (␤ ⫽ 0.28; p ⬍ 0.05) were predictors of adolescent self-reported self-esteem, with white adolescents and adolescents who had mothers reporting greater psychological distress self-reporting lower self-esteem. Higher adolescent zBMI (i.e., greater degree of overweight) was the only significant predictor of adolescent self-report of poorer parent-child relations (␤ ⫽ ⫺0.27; p ⬍ 0.05). There were no significant predictors of adolescent self-report of problematic interpersonal relations with peers or anxiety symptomatology. Insurance status was not a significant predictor in any model of adolescent self-report when examining BASC-SRP scale scores. Prediction of Mother-Report of Child/Adolescent PRS Child. As summarized in Table 6, mother-report of child Internalizing and Externalizing problems were predicted by both maternal distress (Internalizing: ␤ ⫽ 0.32; p ⬍ 0.01; Externalizing: ␤ ⫽ 0.26; p ⬍ 0.05) and insurance status (Internalizing: ␤ ⫽ ⫺0.34; p ⬍ 0.05; Externalizing: ␤ ⫽ ⫺0.43; p ⬍ 0.01). Children who were Medicaid recipients and children with mothers reporting greater maternal distress were described as having greater internalizing and OBESITY RESEARCH Vol. 12 No. 10 October 2004

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Table 4. Zero-order intercorrelations for BASC-SRP (self-report), BASC-PRS (mother-report), demographic variables, child zBMI, maternal distress, and maternal BMI for adolescents (n ⫽ 59; age, 12 to 18 years)

1. 2. 3. 4. 5. 6. 7. 8. 9. 10. 11. 12. 13. 14. 15.

Insurance Gender Race Child zBMI Social stress§ Anxiety§ Depression§ Relations with parents§** Interpersonal relations§ Self-esteem§ Adaptive skills¶** Internalizing¶ Externalizing¶ Maternal distress (GSI) Maternal BMI††

1

2

3

4

5

6

⫺.02 ⫺.46‡ ⫺.00 ⫺.06 ⫺.04 ⫺.14 .15 .13 ⫺.15 ⫺.09 ⫺.05 ⫺.14 .07 ⫺.20

⫺.01 ⫺.05 .12 .09 .04 .09 ⫺.04 ⫺.10 .06 .03 ⫺.16 .05 ⫺.13

⫺.04 ⫺.08 .03 .02 .05 ⫺.01 .30* .02 ⫺.09 .13 ⫺.05 .41†

.10 .07 ⫺.06 ⫺.29* .13 ⫺.06 ⫺.03 .07 .15 .11 .08

.68‡ .72‡ ⫺.41† ⫺.59‡ ⫺.70‡ ⫺.08 .45‡ .28* .40† .15

.41† ⫺.16† ⫺.51‡ ⫺.48‡ ⫺.19 .36† .15 .20 .17

7

8

9

10

11

12

13

14 15

⫺.57‡ ⫺.67‡ .22 ⫺.67‡ .42† .48‡ ⫺.18 .24 .27* .15 .40† ⫺.29* ⫺.20 ⫺.47† ⫺.25 .35† ⫺.52‡ ⫺.09 ⫺.21 ⫺.36† .64‡ .30* ⫺.20 ⫺.05 ⫺.39† ⫺.04 .48‡ .44† .17 .04 ⫺.04 .03 ⫺.16 .09 .12 .07

* p ⬍ .05; † p ⬍ .01, ‡ p ⬍ .001. § BASC-SRP (adolescent self-report). ¶ BASC-PRS (mother-report). ** Low scores indicate less desirable characteristics. †† Intercorrelations with maternal BMI are based on a smaller sample (n ⫽ 53 adolescents).

externalizing difficulties than those children who were insured/self-paying or whose mothers reported lower distress. Mother-report of greater child Adaptive Skills (i.e., positive behavior) was predicted by insurance status (␤ ⫽ 0.43; p ⬍ 0.01) and maternal distress (␤ ⫽ ⫺0.24; p ⬍ 0.05). Children who were insured/self-paying and those with mothers reporting lower distress were described by mothers as having more positive behaviors than those receiving Medicaid or those with mothers reporting higher maternal distress. In summary, insurance status and maternal distress were important predictors of all three composite scores of motherreport of child psychological adjustment. Race and degree of child overweight were not significantly associated with any parent-report of child psychological adjustment. Adolescent. As summarized in Table 6, greater maternal psychological distress was the only significant predictor of mother-report of increased adolescent Externalizing (␤ ⫽ 0.44; p ⬍ 0.001) and Internalizing (␤ ⫽ 0.48; p ⬍ 0.001) problems. No factors accounted for significant variance in predicting mother-report of adolescent Adaptive Skills. Race, degree of adolescent overweight, and insurance status were not significantly associated with any mother-report of adolescent psychological adjustment as measured by BASC-PRS composite scores. 1582


Discussion The psychological adjustment of obese children and adolescents seeking clinical weight management treatment was not characterized by universally high levels of maladaptive behavior or problematic psychological functioning compared with a general normative sample, according to the report of mothers or youths themselves. However, many mothers of obese children and adolescents described their offspring as being “at risk” for internalizing symptomatology, such as greater depression, anxiety, and somatization. Adolescents were also described by their mothers as being more socially withdrawn and isolated, on average, than the age normative sample. Furthermore, the observed base rates of mother-reported at-risk/clinical range scores for internalizing symptomatology, withdrawal, and impaired social skills were significantly higher than corresponding rates in the general population based on published norms. Obese children and adolescents did not self-report experiencing difficulties across all aspects of psychological functioning, but a significant percentage of adolescents reported greater somatic complaints and lower self-esteem than observed in the general population. Present findings are consistent with prior research among mothers of obese children in both clinical (7) and research settings (9), but present rates of


Table 5. Hierarchical regression analysis predicting self-report of child (n ⫽ 62) and adolescent (n ⫽ 59) psychological adjustment

BASC-SRP Composite Hierarchical Step Child Step 1: Race Step 2: Race, Step 3: Race, Step 4: Race, Insurance Adolescent Step 1: Race Step 2: Race, Step 3: Race, Step 4: Race, Insurance

zBMI§ zBMI, GSI储 zBMI, GSI,

zBMI zBMI, GSI zBMI, GSI,

Depression

Anxiety

R

⌬R

R

⌬R

.01 .11 .49

.01 .00 .23‡

.04 .05 .20

.49

.00

.02 .06 .31 .35

Social Stress

Self-Esteem

Interpersonal Relations

Relations with Parents

R

⌬R

R

⌬ R2

R

⌬ R2

R

⌬ R2

.00 .00 .04

.04 .06 .36

.00 .00 .13†

.11 .20 .35

.01 .03 .08*

.01 .08 .37

.00 .01 .13†

.03 .03 .38

.00 .00 .15†

.21

.00

.36

.10

.39

.03

.41

.03

.41

.01

.00 .00 .10*

.03 .07 .21

.00 .01 .04

.08 .12 .41

.01 .01 .15†

.30 .30 .48

.09* .00 .14†

.01 .13 .14

.00 .02 .00

.05 .29 .34

.00 .09* .03

.03

.22

.00

.43

.01

.48

.00

.21

.02

.39

.03

2

2

2

* p ⬍ .05; † p ⬍ .01, ‡ p ⬍ .001. § zBMI ⫽ youth BMI standardized to age and gender norms. 储 GSI ⫽ Global Severity Index of SCL90R measuring maternal distress.

Table 6. Hierarchical regression analysis predicting mother-report of child (n ⫽ 62) and adolescent (n ⫽ 59) psychological adjustment

BASC-SRP Composite Hierarchical Step Child Step 1: Race Step 2: Race, Step 3: Race, Step 4: Race, Adolescent Step 1: Race Step 2: Race, Step 3: Race, Step 4: Race,

Internalizing

Adaptive Skills

Externalizing

R

⌬ R2

R

⌬ R2

R

⌬ R2

zBMI§ zBMI, GSI储 zBMI, GSI, Insurance

.03 .24 .45 .52

.00 .06 .15† .06*

.12 .14 .37 .48

.01 .01 .12† .10†

.30 .32 .45 .54

.09 .01 .10† .10†

zBMI zBMI, GSI zBMI, GSI, Insurance

.09 .11 .48 .49

.00 .06 .15‡ .06

.13 .20 .48 .49

.02 .02 .19‡ .01

.02 .03 .05 .11

.00 .00 .00 .01

* p ⬍ .05; † p ⬍ .01, ‡ p ⬍ .001. § zBMI ⫽ youth BMI standardized to age and gender norms. 储 GSI ⫽ Global Severity Index of SCL90R measuring maternal distress.


1583


youths with at-risk/clinically significant psychological adjustment difficulties were generally higher than in prior studies, perhaps because of sample (research vs. clinical; less demographically homogeneous) or assessment method differences. The higher rates of psychological maladjustment found within this clinical sample warrant attention from pediatric obesity treatment practitioners. Mother-reported child and adolescent psychological difficulties were often most strongly associated with the mothers’ own level of psychological distress, and for children specifically, with their insurance status (i.e., socioeconomic status), rather than with other youth characteristics (e.g., percent overweight, race). This finding replicated prior work by Epstein et al. (8,9) among samples of obese children (age, 8 to 12 years) and extended these findings to obese adolescents. These data also expanded the empirical literature by documenting that child and adolescent selfreport of their own psychological adjustment was also most strongly associated with their mother’s level of psychological distress rather than with youth or demographic factors. It has been argued that maternal depressive mood may distort a mother’s perceptions of child behavioral problems (14,15,22), although this assertion has not gone unchallenged (23). By obtaining youth self-report, this study improves on prior research characterized by single-source (e.g., mother) designs (6,9) and studies for which sole reliance on mother-report is a potential confound (7–9). In this study, lower SES, as measured by Medicaid status, was related to mother-report of poorer child, but not adolescent, psychological adjustment. Compared with mothers with higher SES (i.e., insured/self-paying), mothers with low SES described their obese children as at risk for greater internalizing and externalizing difficulties, as well as having fewer adaptive skills. Follow-up analyses revealed that mothers with low SES reported higher psychological distress for themselves than mothers with higher SES (Medicaid GSI ⫽ 60.6 ⫾ 10.1; insured/self-paying GSI ⫽ 54.7 ⫾ 8.5; t ⫽ 2.42; p ⬍ 0.05). Post hoc analyses showed that maternal distress (Step 2) mediated the relationship between insurance status (Step 1) and mother-report of child internalizing problems (Step 1: insurance status ␤ ⫽ ⫺0.28, p ⬍ 0.05; Step 2: insurance status ␤ ⫽ ⫺0.18, not significant, GSI ␤ ⫽ 0.34, p ⬍ 0.01). These data suggest that low SES is associated with mother-report of internalizing problems for obese children only if the mother is distressed. In contrast, maternal distress did not mediate the relationship between insurance status and externalizing problems or adaptive skills, suggesting SES and maternal distress are independent predictors of child outcomes. Interestingly, SES was not related to mother-report of adolescent psychological adjustment, nor was SES a significant predictor of any child or adolescent self-report of psychological adjustment. Present and prior findings (8) lend support for careful 1584


analysis of the interaction of SES and maternal distress when examining the psychological correlates of pediatric obesity. Strong associations between greater maternal distress and child or adolescent psychological adjustment problems are not unique to obese youth (24,25). Furthermore, parental psychopathology is known to disrupt parenting and the family environment. Maternal depression, in particular, has been linked to negativity and indifference in the parentchild relationship, inconsistent parenting, and poorer physical and psychological health outcomes in children (26,27). The consistent association between maternal and both child and adolescent psychological adjustment is particularly problematic, given the higher prevalence of maternal distress reported in this sample. The prevalence of clinically significant maternal distress was markedly higher in this sample of mothers seeking weight treatment for their children (⬃50%) than in prior studies (8,9). Interestingly, despite the high rate of obesity in mothers, it was unrelated to her level of distress. These findings have potential implications for familybased weight control treatment, particularly among clinicbased samples. For example, maternal distress may cause disruptions in parenting practices that reduce the effectiveness of parenting skills needed to support child weight control (28). However, no studies to date have specifically examined the impact of parent distress on parenting practices in families with an obese child or adolescent. Future research should also address whether high maternal distress is a unique phenomenon for treatment-seeking mothers or whether high psychological distress is also present among non–treatment-seeking mothers of obese youth. Greater maternal distress and mothers’ perceptions of their child/adolescent’s poorer psychological and social functioning could be leading mothers to pursue weight treatment for their obese child/adolescent. Alternately, mothers without their own or perceived child’s psychological adjustment problems may not be seeking weight control treatment for their obese children. This is consistent with evidence that mothers do not necessarily appreciate the physical health risk associated with obesity in childhood (29). Indeed, a significant percentage of mothers do not perceive their obese children as obese, and some indicate only becoming concerned about their child’s weight if the child was being teased by peers (30,31). Whether maternal distress becomes a barrier to treatment success remains an unexplored empirical question requiring further examination. It is conceivable that incorporating interventions that specifically target maternal distress into behavioral intervention models might improve both the psychological status of the child and the mother, and obesity treatment outcomes. The hypothesis that child and adolescent degree of overweight would be an independent predictor of child/adolescent psychological adjustment after controlling for maternal distress and demographic factors was not supported. It is


possible that the relationship between child/adolescent psychological adjustment and degree of overweight may not be consistently linear, or a child/adolescent’s weight may need to hit a particular threshold for psychological difficulties to develop. The restricted range of degree of overweight (all had BMIs ⱖ95th percentile) in this study limited a full exploration of these questions, which would require comparing children at different degrees of overweight rather than smaller gradations. To examine this further, we conducted post hoc analyses to determine whether there were differences in the measures of psychological adjustment when comparing those whose zBMI measured within either extreme quartile (1st to 25th vs. 75th to 99th) and found no significant group differences for children or adolescents. Thus, these data documented that, within an exclusively obese sample, there is no support for the hypothesis that those who are more severely obese are experiencing more psychological adjustment issues than those who are less severely obese. Race was generally not a significant predictor of child and adolescent psychological adjustment. However, white adolescents self-reported lower self-esteem than black adolescents. Thus, these data provide additional empirical evidence that race may moderate the relation between obesity and self-concept for adolescents (32). The more positive self-esteem of black adolescents should be seen as a strength to be emphasized in intervention efforts. However, these data may also reflect a less negative cultural context for obesity in black culture, which, while promoting better self-esteem, may also may present unique barriers to successful weight management for black youth (33–36). This study makes a number of important contributions to the empirical evidence regarding obese youths’ psychological adjustment, but it is not without limitations. The lack of a control group (e.g., nonobese, non–treatment-seeking obese) necessitated reliance of comparisons to instrument norms. The use of insurance status as a proxy variable for SES limits the ability to fully capture the social and economic circumstances of the participating households that may prove important to understanding how economic context is associated with pediatric obesity and its psychological correlates. This study was designed to assess traditionally defined dimensions of psychological adjustment, but this and prior research have not directly assessed more contextual information of the daily lives of obese children and adolescents, such as peer group and family factors that may be correlates of pediatric obesity, treatment efficacy, and/or psychological functioning within this increasingly prevalent population. For instance, recent data suggest that obese children have significantly compromised perceived health quality of life, with levels similar to children diagnosed with cancer (37). Recent evidence has suggested that overweight adolescents are more socially marginalized than their non-overweight peers, being much less likely to be

identified as friends and having friends who are less popular themselves (38). Some of the obese children and adolescents in this study self-reported significant interpersonal difficulties, and many were described by mothers as being socially withdrawn. While parent- and self-report of peer relations may provide some information about how obese youth fare in the peer environment, both peers and teachers have been established as favored, as well as reliable and valid, sources for assessment of child and adolescent social functioning (39). Future research should use peer- and other-report methodologies, because this may improve our understanding of the impact of obesity on children’s concurrent and future adjustment and help to identify social behaviors that could impact successful weight management. Given the important role of maternal distress in this population, further examination of additional family correlates such as paternal psychological health, family functioning (i.e., cohesion, conflict), child-rearing practices, and the parent-child relationship is long overdue. Such exploration would potentially identify variables that could be targeted to maintain positive lifestyle changes necessary for successful weight management among obese children and adolescents.

Acknowledgments This research was funded by grants from the Cincinnati Children’s Hospital Research Foundation and the NIH (DK60031) to M. H. Zeller and a grant from the NIH (DK60476) to B. E. Saelens. References 1. Ogden CL, Flegal KM, Carroll MD, Johnson CL. Prevalence and trends in overweight among US children and adolescents, 1999 –2000. JAMA. 2002;288:1728 –32. 2. Must A, Jacques PF, Dallal GE, Bajema CJ, Dietz WH. Long-term morbidity and mortality of overweight adolescents. A follow-up of the Harvard Growth Study of 1922 to 1935. N Engl J Med. 1992;327:1350 –5. 3. Gortmaker SL, Must A, Perrin JM, Sobol AM, Dietz WH. Social and economic consequences of overweight in adolescence and young adulthood. N Engl J Med. 1993;329:1008 – 12. 4. Lamertz CM, Jacobi C, Yassouridis A, Arnold K, Henkel AW. Are obese adolescents and young adults at higher risk for mental disorders? A community survey. Obes Res. 2002;10: 1152– 60. 5. Banis HT, Varni JW, Wallander JL, et al. Psychological and social adjustment of obese children and their families. Child Care Health Dev. 1988;14:157–73. 6. Israel AC, Shapiro LS. Behavior problems of obese children enrolling in a weight reduction program. J Pediatr Psychol. 1985;10:449 – 60. 7. Braet C, Mervielde I, Vandereycken W. Psychological aspects of childhood obesity: a controlled study in a clinical and nonclinical sample. J Pediatr Psychol. 1997;22:59 –71. OBESITY RESEARCH Vol. 12 No. 10 October 2004

1585


8. Epstein LH, Myers MD, Anderson K. The association of maternal psychopathology and family socioeconomic status with psychological problems in obese children. Obes Res. 1996;4:65–74. 9. Epstein LH, Klein KR, Wisniewski L. Child and parent factors that influence psychological problems in obese children. Int J Eat Disord. 1994;15:151– 8. 10. Epstein LH, Paluch RA, Gordy CC, Saelens BE, Ernst MM. Problem solving in the treatment of childhood obesity. J Consult Clin Psychol. 2000;68:717–21. 11. Tershakovec AM, Weller SC, Gallagher PR. Obesity, school performance and behaviour of black, urban elementary school children. Int J Obes Relat Metab Disord. 1994;18: 323–7. 12. Epstein LH, Wing RR. Behavioral treatment of childhood obesity. Psychol Bull. 1987;101:331– 42. 13. Smolak L, Levine MP, Striegel-Moore RH. The Developmental Psychopathology of Eating Disorders: Implications for Research, Prevention, and Treatment. Mahwah, NJ: L. Erlbaum Associates; 1996. 14. Sanger MS, MacLean WE Jr, Van Slyke DA. Relation between maternal characteristics and child behavior ratings. Implications for interpreting behavior checklists. Clin Pediatr (Phila). 1992;31:461– 6. 15. Renouf AG, Kovacs M. Concordance between mothers’ reports and children’s self-reports of depressive symptoms: a longitudinal study. J Am Acad Child Adolesc Psychiatr. 1994; 33:208 –16. 16. Kuczmarski RJ, Ogden CL, Grummer-Strawn LM, et al. CDC growth charts: United States. Adv Data. 2000;314:1–27. 17. Kuczmarski MF, Kuczmarski RJ, Najjar M. Effects of age on validity of self-reported height, weight, and body mass index: findings from the Third National Health and Nutrition Examination Survey, 1988 –1994. J Am Diet Assoc 2001;101: 28 –34. 18. Reynolds CR, Kamphaus RW. Behavior Assessment System for Children: Manual. Circle Pines, MN: American Guidance Service; 1992. 19. Brown LL, Hammill DD. Behavior Rating Profile. Austin, TX: PRO-ED; 1983. 20. Achenbach TM, Edelbrock CS. Manual for the Child Behavior Checklist and Revised Child Behavior Profile. Burlington, VT: University of Vermont; 1983. 21. Derogatis LR. SCL-90-R: Administration, Scoring, and Procedures. Towson, MD: Clinical Psychometric Research; 1983. 22. Krech KH, Johnston C. The relationship of depressed mood and life stress to maternal perceptions of child behavior. J Clin Child Psychol. 1992;21:115–122. 23. Richters J, Pellegrini D. Depressed mothers’ judgments about their children: an examination of the depression-distortion hypothesis. Child Dev. 1989;60:1068 –75.

1586


24. Anderson CA, Hammen CL. Psychosocial outcomes of children of unipolar depressed, bipolar, medically ill, and normal women: a longitudinal study. J Consult Clin Psychol. 1993; 61:448 –54. 25. Goodman SH, Gotlib IH. Risk for psychopathology in the children of depressed mothers: a developmental model for understanding mechanisms of transmission. Psychol Rev. 1999;106:458 –90. 26. Burke L. The impact of maternal depression on familial relationships. Int Rev Psychiatry. 2003;15:243–55. 27. Beardslee WR, Versage EM, Gladstone TR. Children of affectively ill parents: a review of the past 10 years. J Am Acad Child Adolesc Psychiatr. 1998;37:1134 – 41. 28. Epstein LH, Wisniewski L, Weng R. Child and parent psychological problems influence child weight control. Obes Res. 1994;2:509 –15. 29. Young-Hyman D, Herman LJ, Scott DL, Schlundt DG. Care giver perception of children’s obesity-related health risk: a study of African American families. Obes Res. 2000;8: 241– 8. 30. Baughcum AE, Powers SW, Johnson SB, et al. Maternal feeding practices and beliefs and their relationships to overweight in early childhood. J Dev Behav Pediatr. 2001;22:391– 408. 31. Jain A, Sherman SN, Chamberlin DL, Carter Y, Powers SW, Whitaker RC. Why don’t low-income mothers worry about their preschoolers being overweight? Pediatrics. 2001; 107:1138 – 46. 32. Strauss RS. Childhood obesity and self-esteem. Pediatrics. 2000;105:e15. 33. Kumanyika S, Wilson JF, Guilford-Davenport M. Weightrelated attitudes and behaviors of black women. J Am Diet Assoc. 1993;93:416 –22. 34. Kumanyika SK. Obesity in minority populations: an epidemiologic assessment. Obes Res. 1994;2:166 – 82. 35. Thompson SH, Corwin SJ, Sargent RG. Ideal body size beliefs and weight concerns of fourth-grade children. Int J Eat Disord. 1997;21:279 – 84. 36. Wilson DB, Sargent R, Dias J. Racial differences in selection of ideal body size in adolescent females. Obes Res. 1994;2: 38 – 43. 37. Schwimmer JB, Burwinkle TM, Varni JW. Health-related quality of life of severely obese children and adolescents. JAMA. 2003;289:1813–9. 38. Strauss RS, Pollack HA. Social marginalization of overweight children. Arch Pediatr Adolesc Med. 2003;157:746 – 52. 39. Newcomb AF, Bukowski WM, Pattee L. Children’s peer relations: a meta-analytic review of popular, rejected, neglected, controversial, and average sociometric status. Psychol Bull. 1993;113:99 –128.