The current study demonstrated that mothers of treatment-seeking obese youth report a parenting style lower in behavioral control and describe their children as temperamentally more difficult relative to mothers of nonoverweight peers. These effects were additive, as parenting style and difficult temperament contributed unique variance above the other, while controlling for maternal weight status. Further, the interaction of difficult temperament and lower maternal warmth differentiated groups of obese and nonoverweight youth. The present study is important as it expands our knowledge of parent and child factors and their interactions that characterize youth whose families present in clinical pediatric weight management settings. As such, these data have important clinical implications and provide direction for future research.
Data from the current study add to a small existing literature9,14
linking parent perceptions of difficult child temperament to childhood obesity. Interestingly, obese youth differed from nonoverweight comparison peers across multiple dimensions of temperament. Relative to comparison peers, obese youth were perceived by mothers as exhibiting lower biological rhythmicity as well as less approach, flexibility, positive mood and persistence. It is possible that aspects of more difficult temperament such as lower flexibility and persistence may result in an obese child or adolescent experiencing greater challenges with regard to making lifestyle changes that impact their daily routine, eating and activity. In addition, given that difficult temperament is predictive of greater internalizing symptoms (for example, depression and anxiety) and poorer social functioning in adolescence and young adulthood,13
obese youth who present in a clinical setting may be at increased psychosocial risk.
Comparison of our parenting data to that of previous researchers proves difficult given the use of different measures of parenting style,8–10
different methods of data collection (for example, observational at mealtimes)34
or more focused assessments of domain-specific parental feeding practices.5–7
The three studies that examined pediatric obesity and general parenting styles focused on combinations of warmth and control (for example, authoritative and authoritarian) and found either no association9,10
or evidence of authoritarian parenting (low warmth and high control) increasing obesity risk.8
However, by examining warmth as well as different aspects of control separately, the current study found that mothers of obese youth had a parenting style characterized by lower behavioral control (for example, fewer rules and less strict), but were not different in terms of warmth or psychological control (for example, guilt), relative to comparisons. Thus, parents who present for weight management treatment for their obese child likely have fewer household rules and are less consistent in discipline practices. Furthermore, while overall, mothers of obese children were similar to comparison mothers in warmth, the interaction of low maternal warmth and difficult temperament proved important in differentiating between groups. Longitudinal studies will therefore be necessary to understand the direction of effects among temperament, parenting and weight status.
Taken together these findings direct investigators to consider and test more complex models of the relation between parent and child characteristics and their mutual role in a weight-related behavior change process. For example, some researchers have suggested that general parenting style may have an indirect effect on child behavior by changing the effectiveness of parenting practices in a given context (for example, diet and activity).35
Therefore, within the context of prescribed pediatric weight loss, it is conceivable that specific parenting practices around child-feeding or reducing sedentary activity may have different effects on child outcomes for children of parents with different parenting styles or on children of different temperaments. For instance, children with difficult temperaments may be resistant to recommended changes in nutrition or activity levels, particularly if their parents have a history of ineffective or limited parenting skills, such as disciplinary strategies. Alternately, on the basis of their recent literature review, Ventura and Birch 36
speculated that child weight can influence what parenting practices are used.
The demonstration of independent effects of maternal overweight, maternal parenting style and difficult temperament suggest that taking all into account in the context of obesity treatment may result in more effective interventions. Parenting interventions aimed at enhancing positive parenting behaviors that also complement the child or adolescent’s behavioral style, and encouraging levels of behavioral control that are age-appropriate may help improve child behavior, the parent’s sense of competence and the parent–child relationship.
This study is the first to our knowledge to demonstrate the transactional nature of the parent–child relationship in the context of pediatric obesity; however, several limitations were noted with consequent directions for future research. Given the present data are cross-sectional, the study design precludes any conclusions regarding the temporal ordering of associations until longitudinal studies are performed. Longitudinal studies are necessary to allow for an understanding of potential reciprocal effects between such variables. Although the clinical relevance of these specific data are clear, it is critical to better understand whether these parenting and temperament patterns are also typical of obese youth in the broader community who do not or cannot access care. Although we did not find evidence of race, gender or age effects in our exploratory analyses, potential differences may become more evident when utilizing a larger sample. This is particularly relevant given literatures that have suggested ethnic differences in parenting style,37
and the rate of increase in prevalence of obesity for ethnic minority groups.38
Because mothers provided the information both on children’s temperament and their own parenting style, it may be argued that the findings on their associations represent merely shared method variance. In particular, given our prior findings that mothers who present their child for pediatric obesity treatment self-report greater psychological distress than comparison mothers,18
it could be argued that distress may lead these mothers to perceive their child as more difficult temperamentally. However, we demonstrated that these clinically referred obese youth are seen as problematic (for example, more withdrawn and lower acceptance) within the peer environment as well.21
Although the weight loss prescription is known (for example, eat less and move more), the pediatric intervention literature has not progressed at a rate to ease the individual, family and societal burden of the epidemic. Efficacy trials of family-based treatments have established strong empirical support,3,4,39
with targeting parent and child together in weight loss, as well as parent training in child behavior management skills as critical components of care. Interestingly, however, the vast majority of clinical trials have not included measures of parenting pre- and post-intervention, nor assessed whether parents were in fact using the parenting skills they were being taught, as measured outcomes focus on weight change. A recent efficacy trial by Stein et al
proves an exception, where better child weight loss outcomes were observed to be associated with an increase in child-report of father warmth in parenting. To our knowledge, no efficacy trials have targeted the ‘fit’ between child temperament and the parenting style in treatment models. Finally, how parent and child interactions lead to the development of obesity and its associated health risk behaviors (for example, physical inactivity and poor diet) is a vitally important area for future research utilizing prospective longitudinal and controlled designs.