ContinuingNursingEducationSeries

Parenting Styles andTreatment of Adolescentswith ObesitySusann RegberKristina Berg-KellyStaffan Marild

The increasing prevalence ofoverweight and obesityamong children and adoles-cents is a matter of great con-

cern. The World Health Organization(WHO) regards obesity as an epidem-ic, equivalent in importance to tradi-tional public health issues such asmalnutrition or infectious diseases(WHO. 2000). A recent estimate ofthe prevalence of overweight and obe-sity in some 140,000 adolescentsbetween 10 and 16 years of age in 34countries revealed that the adolescentobesity epidemic is a global issue(Janssen et al.. 2005). The authorsconcluded that efforts must be multi-plied at all levels to promote physicalactivity, a healthy diet, and healthybody weight.

Egger and Swinburn (1997) havesuggested an ecological approach tothe obesity pandemic. Their modelproposes three main influences: (a)biological, (b) behavioral, and (c)environmental. A shift from the tradi-tional focus on the individual to theenyironmental influences is necessary

Susann Regber, MPH. RN, is a PediatricrSurse, Queen Silvia Children's Hospital,Goteborg, Sweden.

Kristina Berg-Kelly. MD. PhD, is AssistantProfessor, Department Of PediatricsMedica! Faculty. Qoteborg, Sweden.

Staffan Marild, MD. PhD, is a consultant.Queen Silvia Children's Hospital,aoteborg, Sweden.

Acknowledgment: This paper was sup-ported by the Western Sweden RegionalHealth Care Authority (VastraGotalandsregionen).

Note: The authors reported no actual orpotential conflict of interest in relation tothis continuing nursing education article.

The CNE Posttestcan be found

on pages 35-36.

Professional caregivers have an important task in building a trustingrelationship with parents and adolescents and in supporting parentsin their parental roles. Our clinical experience of some 300 adoles-cents with obesity between 9 and 18 years of age and their parentshas convinced us that consideration of parenting styles is fundamen-tal in the treatment of children and adolescents with obesity. Typicalcase situations supporting the significance of parenting styles andillustrating the relationships between parents and adolescents withobesity can be identified. Group sessions with parents are the pre-ferred mode for discussing typical parenting issues in the manage-ment of obese adolescents. The purpose of this paper is to describedifferent parenting styles, and to present a set of typical case situa-tions and treatment strategies for nurses working with adolescentswith obesity.

to fight the obesity pandemic. Modernsociety is "obesogenic" with micro-(the environment close to the individ-ual) and macroenvironments (soci-ety). The microenvironment includeshousehold rules for watching TV andvideo, the use of cars instead of walk-ing, and family eating and recreationpatterns. The macroenvironment isrepresented by societal regulationslike food laws, food taxes, subsidies,and the infrastructure of cyclewaysand walkways. In the treatment ofadolescents with obesity, parents arekey persons regarding changing themicroenvironment. Involving parentsin treatment may therefore have ahuge impact on the eating habits andphysical activities of adolescents.

Definition of ObesityAt the Queen Silvia Children's

Hospital in Goteborg, Sweden, we usethe international age- and gender-spe-cific body mass index (BMI) cut-offpoints, at the age of 2-18 years, todefine overweight and obesity. Thesedefinitions were proposed by theInternational Obesity Task Force(lOTF) (Cole. Bellizi, Flegal, & Dietz,2000). The different child BMI cut-offscorrespond to the adult cut-off pointsof 25 and 30 kg/m^ defining over-weight and obesity respectively(WHO, 2000). The Centers for

Disease Control and Prevention(CDC) (2005) recommends the use ofBMl-for-age percentiles. where chil-dren and adolescents between the85th percentile and < 95th percentileare defined as being at risk of over-weight, while those at the = 95th per-centile are defined as overweight. Inthis paper, we therefore use the lOTFterm "overweight." which correspondsapproximately to the CDC term "riskof overweight." and the lOTF term"obesity" for the CDC term "over-weight."

Psychosocial Development inAdolescents

In planning treatment, profession-als must be familiar with the role ofage and developmental phase of theindividual adolescent in to address thespecific health consequences of obe-sity and the long-term consequencesin the optima! manner. Meinstein,Juliani. and Shapiro (1996) describedthree psychosocial developmentalphases and several tasks that charac-terize the various phases of adoles-cence. The three phases are (a) earlyadolescence (approximate 10-13years of age), (b) middle adolescence(approximate 14-!6 years of age),and (c) late adolescence (approxi-mate 17-2! years of age). The tasksthat are in conjunction with the psy-

PEDIATRIC NURSING/Janaury-Tebrua"ryZD07/voi. 33/NO. l

Rgure 1. Health Consequences Associated with Adolescent Obesity

Health Consequences Associated withAdolescent Obesity

Psychologicalproblems ^

Poor self-esteem ^^i^^^.-^—-Depression ^^^^^^^^^^^^^Eating disorders W^^ -e*̂ t l

\ — r

Gastro-intestinal / ^ , \M I 1 V"

problems m \ \m f - \

Gallstones R / ' 1Steatohepatitis W

^ ^ , ^Endocrine problems p H ^ H B ^ l ^ HType 2 diabetes 1 ^^ 1

Precocious puberty 1 j f I t , APolycystic ovaries E f ^ H B(girls) 1 # ^ H ^Hypogonadism V f | ^ ^ H(boys) %^ ^ S

Neurological____-- problems

Headache

PulmonaryN̂ problems

"••\ Sleep apnea

\ Asthma

/ CardiovascularHypertension

Dyslipidemia

Coagulopathy

\ ^ ^ Musculoskeletal•—

Disorders

• Flat feet

Source: From Ebbeling, C, Pawlak, B., & Ludwig, D. (2002). Childhood obesity: Public health crisis, common sense andcure. Lancet 360, 473-482. Reprinted with permission.

PEDIATRIC NURSING/Janaury-February 2007/Vol. 33/No. 1

chosocial developmental phasesinclude (a) achieving independencefrom parents, (b) adopting peer codesand lifestyles, (c) assigning increasedimportance to body image and accep-tance of one's body image, and (d)establishing sexual, ego, vocationaland moral identities. Elkind (1967)described an egocentric way of think-ing in adolescence that might havesocial implications for adolescents.Egocentric adolescents are unable todistinguish between their ownthoughts and those of others. Elkindalso explained that adolescents oftenfeel as if they are being observed by acritical "imaginary audience," con-stantly attentive to how they look,talk, and behave. This may lead to alack of self-confidence in social situa-tions.

Consequences of ObesityFrom the adolescent perspective,

the most severe consequences of obe-sity are the psychological and socialissues, including poor self-esteem andstigmatization (Strauss, 2000).Strauss conducted a 4-year follow-upstudy of 1,520 children, ranging from9-10 years of age at the initiation ofthe study. This study reported increas-ing levels of loneliness, sadness, andnervousness among adolescents whowere obese.

Health consequences. The health-related quality of life of severely obesechildren and adolescents has beenshown to be lower than that of healthychildren and adolescents and equiva-lent to that of subjects with cancer(Schwimmer, Burwinkle & Varni,2003). The medical consequences ofobesity begin to affect physical healthbecause most ofthe overt adult obesi-ty-related morbidity, such as hyper-tension, type 2 diabetes, hyperiipi-demia, gal! bladder disease,osteoarthritis and musculoskeleta!disorders, starts to develop in child-hood (Ebbeling, Pawlak & Ludwig2002) (see Figure I) .

Long-term consequences. Thesocial and economic consequences ofobesity during adolescence aregreater than those of many otherchronic physical disorders and oneexplanation is that discrimination mayaccount for these results, according toGortmaker. Must, Perrin, Sobol, andDietz (1993). The researchersprospectively examined the relation-ship between obese adolescents (370subjects) among 10,039 adolescentsand young adults, and their social andeconomic characteristics and self-esteem between 1981 and 1988. Theyfound that obese adolescents had

Table 1. Requirements for the Caregiver

Theoretical knowledge of adolescent health and medical health conse-quences of obesityAbility to support empowerment of the adolescentSkills in motivational interviewingAbility to support parents in becoming central agents of changeProficiency in behavioral management strategiesGuidance in parenting techniquesCommunication skills in addressing family conflicts

completed fewer years of education,married less often, and had lowerhousehold incomes and lower self-esteem in early adult life than theirnon-obese counterparts, regardless ofsocio-economic origin. In a recentstudy, however, Viner and Cole (2005)suggested that the adversity of obesi-ty might be less than previouslyreported. The authors studied a Britishcohort of ! 6, 567 babies born in 1970that were followed up at 5, 10 and 29-30 years, measuring obesity at 10years and 30 years. Self-reportedsocio-economic, educational, psycho-logical, and social outcomes weremeasured at 30 years. They foundthat obesity limited to childhood haslittle impact on adult outcomes,although persistent obesity in womenis associated with poorer employmentand relationship outcomes.

Requirements for ProfessionalCaregivers

Caregivers need to develop higherskills in behavioral managementstrategies and parenting techniques tosupport parents more effectively intheir roles. Story et al. (2002) studiedattitudes, perceived barriers, per-ceived skill levels, and training needsin the management of children andadolescents with obesity amonghealth care professionals in the USA.The researchers found that pediatricpractitioners view child and adoles-cent obesity with concern and feel thatintervention is important, but thatthere are various barriers to be over-come. The reported barriers were lackof parental involvement, lack ofpatient motivation, lack of insurancesupport for reimbursement, and lackof time. The health care professionalswanted higher proficiency in the use ofbehavioral management strategiesand guidance in parenting techniquesand the addressing of family conflicts(see Table 1). The results of the studyhave been summarized with recom-mendations for the management ofchild and adolescent obesity (Barlow& Dietz. 2002).

Communication skills. In our expe-

rience, it is important that informationto parents and adolescents about thehealth consequences of obesity bepresented with an empathetic attitudeand with a knowledge of the specificmaturation process during adoles-cence. An adolescent with obesityalso must be helped to see that his/hersituation can change. It is a challengefor pediatric nurses and other healthprofessionals to provide incentives forempowerment and to help these indi-viduals to obtain motivation andstrength to improve their self-esteemand achieve effective weight manage-ment. Building up a trusting relation-ship and helping each particular ado-lescent find his or her positive person-al power to transform a negative self-image into a positive one paves theway for treatment.

Motivational interviewing. Themethod of asking the patient keyquestions about the importance ofchange, with the aim of moving thepatient in the direction of readiness tochange his or her behavior, is knownas motivational interviewing (Sindelar,Abrantes, Hart, Lewander. & Spirito,2004) and it is useful in the treatmentof adolescents with obesity. Motiva-tional interviewing also is a convenientmethod in the dialog with parents tocommunicate the fact that they areregarded as the central agents ofchange and the key to weight reduc-tion for their adolescents.

Treatment Programs forAdolescents with Obesity

In 2000. the Queen SilviaChildren's Hospital established a teamfor the treatment of children and ado-lescents with obesity. A pediatrician.dietician, physiotherapist, and twopediatric nurse practitioners (PMPs)were recruited and received financialsupport from research funds. To date,more than 300 children and adoies-cents from 9-18 years of age havebeen enrolled in various weight man-agement programs. Most of thepatients are referred by the schoolhealth care and outpatient pediatricdepartments.

PEDIATRIC NURSING/Janaury-February 2007/Vol. 33/No. 1

Description of programs. We offertwo treatment programs. "The BasicProgram" and "The GRIND-studyResearch Program." The BasicProgram targets parents and theiradoiescent children, aged 13-18years. This program offers a series offive sessions to adolescents and theirparents to provide basic facts about(a) health consequences, {b and c)healthy diet, (d) physical activity, and(e) lifestyle behavior modification.The PNPs conduct the parent andadolescent groups' lifestyle behaviormodification sessions, which meetseparately. The pediatrician, dietician,and the physiotherapist give the otherlectures. These sessions are held withparents and adolescents together. Inparallel, the families also are offeredmedical examinations with bloodsamples, a test of physical fitness, andone individual appointment with eachof the following practitioners: a pedia-trician, a PNP, a dietician, and a phys-iotherapist.

The research program ("TheGRIhD-study," group vs. individualtreatment) offers children aged 9-12and their parents the opportunity toparticipate in a 12-month programwith random assignment to eithergroup or individual treatment. Eachgroup has 12 parents and 12 children.in the individual treatment group, fol-lowing the pediatrician's diagnosticevaluation, the dietician, the PMP, andthe physiotherapist meet with the par-ent and child alternately once a monthfor I year. In the group treatment,adolescents meet with the physiother-apist for aerobics. The PMP and dieti-cian provide advice to parents about ahealthy diet and parenting skills forlifestyle modifications in the family.The group treatment includes 20weekly meetings during the first 6months, followed by 4 meetings dur-ing the next 6 months.

Tools in health education. We use aprinted folder presenting examples ofrecommended menus. The folder isused in the treatment of both pro-grams. A recommendation is given toall age groups to have breakfast,school lunch, and dinner as the princi-pal meals, and to add a piece of fruitor one sandwich once in betweenthese meals. The importance of eatingmore vegetables and fresh fruits ingeneral and of adding vegetables toevery meal is emphasized. Candies,snacks, white bread, and sweetenedsoft drinks should be limited to once aweek and, regarding candy, the limit-ed amount of 1 hectogram (--3'/3ounces) is the rule. One page in thefolder also gives recommendations on

physical activity, such as always tak-ing the stairs instead of the elevator,walking or cycling to school, partici-pating actively in physical activities ofall kinds, such as swimming and play-ing outdoors, and also reducingsedentary activities like computergames, TV, and video.

Success rate of the treatment pro-grams. As of October 2004, 280 chil-dren and adolescents have been regis-tered for treatment with our teamsince January 2000. Of these, 180children and adolescents have beenfollowed for at least one year. We havecalculated the preliminary treatmentoutcome in terms of the BMIexpressed in a BMI-standard deviationscore (BMI, SDS) for these childrenand adolescents. At referral, the groupmean BMI. SDS was m = 3.33 (SD.0.59), while, at the very first visit tothe team, the group mean BMI, SDSwas m = 3.28 (SD. 0.61). On the verylast visit, after 1-4 years, mean 2.4years, the group mean BMI SDS wasm = 2.90 (SD, 0.72). The mean agesof the children and adolescents werem = 11.6, 12.5, and 14.9 on the threedifferent occasions mentioned above.So approximately two-thirds dis-played a reduction in BMI, while one-third had increased their BMI (unpub-lished data, Marild. S.).

Parental role in treatment. Theparents in our treatment programshave often expressed guilt about theobesity of their daughter or son. Inaddition, the parents have felt worriedabout the health of their adolescent.Many parents also have expressed asense of having lost control of the sit-uation. Usually, the adolescent hasbeen gaining weight over such a longperiod of time that the parents havefelt unable to stop the process. Thewillingness of parents to participate intreatment has therefore often been apositive sign. However, many parentsare unaware of how much effort andhow many changes will be required ofthem, as well as of their adolescent. Inspite of this, parental participation inthe treatment of obesity in childrenand adolescents has been studied invarious intervention programs andhas proven to be important for thelong-term success of weight reduc-tion.

Brownell, Kelman, and Stunkard(1983} found that a program ofbehavior modification with parentalinvolvement could lead to significantweight reduction in obese adoles-cents. There were three differentexperimental conditions with adoles-cents 12 and 18 years of age with orwithout their mothers: (a) mothers

and adolescents met concurrently inseparate groups, (b) mothers andadolescents met together in the samegroup, and (c) adolescents met alone.The group in which the mothers andadolescents were separated showedthe best results, with a mean weightreduction of 20%, as compared withthe other two groups where the meanweight loss was only 5%. Epstein(1996) reported significantly largerweight reduction in a 10-year follow-up in a group in which both parent andchild were targeted for weight losscompared with a group where childrenwere targeted alone and a non-target-ed control group. Golan and Crow(2004) targeted parents alone, follow-ing a family-based, health-centeredapproach where parents were encour-aged to practice authoritative parent-ing style. The results were comparedwith a control intervention where onlychildren were targeted. Seven yearsafter the intervention, the mean reduc-tion in percent overweight was greaterat all follow up points in children of theparent-only group compared with thechildren-only group.

Parental support. As caregivers inour treatment programs we give par-ents concrete advice and support intheir parenting roie. such as recom-mending parents to praise a positivebehavioral change or encourage non-sedentary activities that parents andadolescents can do together. Anotherpiece of advice is not to include food.ice cream, or sugar-sweetened softdrinks as rewards or to regulatemoods. When advising parents, atti-tudes and basic values in parentingare important issues to cover. Golanand Weizman (2001) emphasize thesupport of parents in parenting-skillsand confidence in bringing up theirchildren in their family-based treat-ment model for the management ofchildhood obesity.

Parental group counseling. Theaim of the group sessions is to makeparents aware of their parenting styleand to give them the opportunity toshare experiences of other parents ofadolescents with obesity. Togetherwith other parents, the feeling of per-sonal guilt is reduced and problem-solving discussions can be fruitful.

One way of opening this dialog withparents is to present and discuss mod-eis of parenting styles. The model ofthe four parenting styles we use wasmodified by Berg-Kelly (1998) (seeTable 2). Using an overhead projector,the figure of parenting styles can beexplained to the assembled parentgroup. The model is well suited toparental group counseling with par-

PEDIATRIC NURSING/Janaury-February 2007/Vol. 33/No. 1

Table 2. Model for Parenting Styles

Empathetic

Cold, Not Empathetic

High Demanding

Authoritative

Authoritarian

Low Demanding

Permissive

Indifferent

ents. When presenting the model, it isalso important to explain that parentsmight recognize themselves in morethan one parenting role, although theymight still feel that one of the parent-ing styles fits them more closely.Because one set of parents could rep-resent two different parenting stylesand because quite a large number ofparents are divorced, the team mustallow both parents to express theirnwn view of the issues that are dis-^ u^sed in the session. Our experienceis that group sessions tend to be posi-tive in atmosphere, neutralizing possi-ble negative aspects and conflictsbetween parents. Silent parents mightLake part in the group sessions andthrough the participation, developnew ideas and attitudes to manage theproblem.

Another important matter toaddress is the situation of siblings inthe family. We discuss the importanceof having the same habits andlifestyles for all the family members,regardless of whether or not they areoverweight.

Models of Parenting StylesThe model and method for parent-

ing role support that we propose wasderived from the application of amodel in which four possible parent-ing models are defined and explained(Baumrind, 1971; Berg-Kelly, 1998;Maccoby & Martin. 1983. In 1971,Baumrind developed four models ofparenting: authoritarian, authoritative,permissive, and rejecting-neglecting(indifferent) parenting styles (see Table2). Maccoby and Martin (1983) havesummarized these styles as follows:

• Authoritarian parents. This par-enting style gives priority toobedience, work, and traditions.Parents shape and control theirchildren in accordance with aset of standards and rules. Therules are not to be discussed orarrived at by argument andinteraction. On the contrary.rules are imposed upon thechild as mandatory and thechild or adolescent is not con-sulted. Authoritarian parentsdiscourage verbal give and takebetween parent and child.

According to Baumrind'sdescription of authoritarian chil-drearing. these parents are verydemanding and very unrespon-sive, which implies that they useverbal directions or orders asopposed to offering suggestionsthat allow the child some free-dom of choice. The authoritari-an parenting style is consideredto have negative effects on theself-esteem of children.Authoritative parents. Parentsare warm and involved, yet stillfirm and consistent in establish-ing limits. This parenting stylealso entails age-appropriaterules and standards and the useof commands and sanctionswhen necessary, along with theencouragement of indepen-dence and individuality. Thechild or adolescent's view is lis-tened to and a verbal give andtake is encouraged. The author-itative, reciprocal parentingstyle has been associated withsocial outcomes such as inde-pendence, self-confidence, andsocially responsible individuals.Permissive parents. This par-enting style is considered moreresponsive than demanding.Parents are tolerant and accept-ing, and avoid imposing con-trols or restrictions. They allowtheir children and adolescents toregulate their own behavior andhave very few rules governingtime schedules, such as bedtimerules, rules for mealtimes. TVwatching, and so on. A permis-sive parent can be either warmor cool and uninvolved.According to Maccoby andMartin (1983, p. 45), "In somecases it undoubtedly reflectsparental inattention and indiffer-ence, rather than commitmentto children's rights." The per-missive parenting style hasmore negative than positiveeffects on the social outcomeand is associated with childrenbeing aggressive, impulsive,and lacking in independenceand a sense of responsibility.Indifferent (rejecting-neglect-

ing) parents. Indifferent parentsare cold and uninterested in theneeds of their children and ado-lescents, reflecting a desire tokeep the child or adolescent at adistance. They try to minimizetime and interaction with thechild or adolescent. This type ofparent is characterized as unin-volved, meaning that they havea low degree of commitment totheir role as parent. There is arisk of a child or adolescentbeing neglected by this type ofparent. Children and adoles-cents brought up by parentswith this parenting style havebeen shown to have negativeeffects in terms of the social out-come, such as lacking in frus-tration tolerance and emotionalcontrol, lacking interest inschoolwork, and lacking in long-term goals for the future. In ado-lescence, they are often in-volved in antisocial behavior,such as excessive drinking anddelinquency (Maccoby & Mar-tin. 1983 p. 50).

Case IllustrationsThe following case illustrations are

age-specific, typical situations that arerelevant in the treatment of adoles-cents with obesity. The first six casescould be used in the dialog and edu-cation program for parents. The sev-enth case is only designed for internaldiscussions by the team and illustratesa set of parents where one has thepermissive parenting role and theother the indifferent parenting role.

Case 1: Permissive parentingmodel. Maria is 13 years old and refus-es to let her motiier be present iviienshe weighs herself. How is a parentsupposed to react to this refusal andhow can the team support the situa-tion in treatment?

The perspective of the adolescent:Maria may be refusing for any of anumber of reasons. One is that shefeels embarrassed and has a sense offailure when it becomes apparent thatshe has gained weight. Second, if it isclear that she has gained weight, andthis is discussed openly, Maria will beurged to make changes she is not yetmotivated to consider. Because shehas been raised in a permissive par-enting style, she is accustomed tosaying no when demands are made ofher.

The perspective of the parent:Because Maria's parents have used apermissive parenting style, Maria isable to take command and continueto refuse. If her mother suddenly

PEDIATRIC NURSING/Janaury-February

begins to use a different parentingstyle, there would probably be a con-flict and permissive parents usuallywant to avoid conflicts for as long aspossible. As was previously men-tioned, parents may feel guilty abouttheir child's weight gain and feel thatthey have lost control. If so, theymight accept Maria's refusal becauseit is a way for them to go on avoidingtaking control.

The perspective of the caregioer:In this case, the adolescent's decisionto keep her weight a secret from theparent makes it difficult to maintain anopen atmosphere and discuss treat-ment strategies effectively. The care-giver can support the parent by dis-cussing the situation with the adoles-cent, explaining the importance ofhaving confidence in his or her parent,and being open about weight, becausethis will make the treatment easier.The caregiver also can support theadolescent by setting reasonablegoals to give the adolescent a fairchance of handling the situation. Afirst goal might be to say, "Let's agreethat you will now stop gaining weightand not let yourself weigh more thanyou do at today's appointment." Byusing a motivating dialog, most ado-lescents accept and agree with thisgoal as they find it feasible. The nexttime, new goals can be set in agree-ment with the adolescent. Anotherproposal to minimize conflicts in rela-tion to the weighing situation is to askthe parents to buy a set of scales andtake responsibility at home for regularv/eighing and to ask the adolescent tokeep a record of his or her weight inbetween the appointments at the clinic.

Case 2: Permissive parentingmodel. Anr}a. who is 10 yeats old,refuses to eat any vegetables apartfrom cucumber and sweet corn. Shesays she doesn't Hice vegetables orfruit. What should tier parents do?

The perspectioe of the adolescent:Anna can see no reason why sheshould eat something she doesn't like.She generally chooses only the foodshe likes and she has done so for sev-eral years without interference fromher parents. She cannot see any rea-son for putting any food she does notlike on her plate.

The perspectioe of the parents:Anna's parents cannot see that theyhave done anything wrong by givingAnna only the food she prefers untilnow. They thought Anna would learnto eat vegetables when she was older.Telling her that she has to try vegeta-bles would probably lead to a conflict,which they want to avoid. They did notrealize vegetables and fruit have to be

introduced into a child's eating habitsat an early stage and that parentshave to be firm to establish this habitin the family. Changing Anna's atti-tude has become a major problem.

The perspectioe of the caregioer: Itis not uncommon for adolescents withobesity only to eat vegetables andsometimes even fruit very sparsely.These adolescents will only learn toeat a varied, healthy diet throughparental mediation and by parentsaiso changing their own modelingbehavior. If the parents do not includevegetables in their own meals, it is dif-ficult to encourage their adolescentchild to do so. Caregivers must there-fore tell the parents that they are rolemodels with regard to this particularhabit. Caregivers indirectly supportparents by working on convincing theadolescent that eating vegetables andfruit is an important part of their workto normalize their weight.

Case 3; Authoritative parentingmodei. Andreas, 1 / years old, joined abasketball club. After attetiditig threesessions he got tired of playittg bas-ketball and wanted to quit. The regis-tration fee had already been paid.How should Andreas'patetUs react?

The perspective of the adolescent:Andreas might have imagined that hewould be an instant success at his newsports activity. When he discoversthere are difficulties to overcome, helooks for an easy way to quit. He can-not run quickly, perspires heavily, getsout of breath easily, and has poor self-confidence. Another problem is thatAndreas is embarrassed about takinga shower with other children.

The perspectioe of the parents:Andreas needs help to overcome hisunwillingness, and he should beencouraged to give both basketballand himself a fair chance before quit-ting. Praising the adolescent forbecoming involved in an activity isone way of giving him or her positiveencouragement. By asking what wasfun and what was less fun, the parentcan help the child find solutions toobstacles that might have initiallybeen unspoken. For instance, the par-ents could suggest taking a shower athome instead of at the club.

The perspectioe of the caregioer:This is a good type of case to discusswith parents. Many parents recognizethis type of experience. This kind ofbehavior is not limited to adolescentswith obesity, which can be empha-sized. Adolescents normally test dif-ferent sports or leisure activitiesbefore finding something with whichthey are happy. Parents can make anagreement with their child before pay-

ing for the sports activity not to quitand start something new until thesemester is over. Parents of adoles-cents with obesity also need to realizethat parental encouragement to not togive up too easily can also be crucialto the whole obesity treatment situa-tion and strengthen the adolescent'sself-confidence.

Case 4: Authoritative parentingmodel. Alexander, 16 years old.spends all iiis after school tinie at iliecomputer Recently, he also has begunstaying up late in the cuetvng onweekends with his friends playir\gcomputer games and drinking softdrinks. Alexander argues that youcan't play computer games withouthaving soft drinks. How sliould iiisparents react?

The perspectioe of the adolescent:Although Alexander wants to reducehis weight, he cannot understand whyhe has to change this particularbehavioral pattern. Alexander isuncertain of the reactions from hispeers if he were to offer them sugar-free soft drinks, for example. Peerpressure and attitudes are very impor-tant to Alexander.

The perspectioe of the parents:Alexander's parents are pleased thathis friends want to come and spendtime at their home, and they find thisteenage activity quite harmless, con-sidering all the dangers to which ado-lescents of his age are exposed.However, they also are confused,knowing that this unlimited consump-tion of high calorie soft drinks coun-teracts the aim of Alexander losingweight.

The perspectioe of the caregioer:This illustrated conflict is one thatmany young people and parentstoday face, and it illustrates the ten-sion that arises for parents, betweenwanting their home to be welcomingand a place of choice for theirteenagers and trying to combat weightgain in their youngster. The consensusamong other parents when discussingthis case is to try to give the adoles-cents alternative beverages that arenot sweetened, such as sugar-free softdrinks, and to try to get the adolescentto agree with this view. Another pointis that making healthy choices is alifelong necessity, the acceptance ofwhich also implies alternative activi-ties that are not as sedentary as play-ing computer games.

Case 5: Authoritarian parentingmodel. This case is similar to case 4above, but with a younger subject.Markus, 11 years of age. ptays com-puter games ujith his friends everyday after school. While he ptays, he

PEDIATRIC NURSING/Janaury-FGbruary 2007/Vol. 33/No. 1

cats snacks and drinks high caloriesofl drinks. What is an appropriateparental reaction to Marcus' behavior?

Comment: An authoritarian par-enting style is the most appropriate inthis situation. It is appropriate to forbideating and drinking in front of thecomputer. In addition to this rule, it isalso necessary to have rules that limitthe amount of time a child spends atthe computer. At a younger age, theparents can use rules and stick firmlyto them, which is sometimes more dif-ficult as the children get older. Thesetwo cases show the necessity of beingflexible in the parenting role, takingthe age of the adolescent intoaccount.

Case 6: Authoritarian parentingmodeL When the family is eating din-ner. Jitnmy. i4 years old. prepares hisown sandwiches Instead of eating theditvier that has been prepared. This istiot an occasional beliavior for Jimniy.it has become a routine and everydaybehavior. Is it acceptable? What advicecan be given by caregivers?

The perspectioe of the adolescent:Jimmy believes that he is old enoughto decide what he wants to eat. He isunaware of how this type of eating isactually maintaining his obesity andleads to intermittent eating during theevening because he has not had aproper dinner. He may be completelyunaware that this behavior is alsoquite challenging and annoying for therest of the family. He may be tooproud to admit he needs support inreducing his weight.

The perspectioe of the parents:Jimmy's habit was established gradu-ally and is now a constant source ofconflict in the family. The parentsdescribe Jimmy as hard to please. Itdoes not matter what kind of dinnerthey make, Jimmy chooses to eatsomething else. Jimmy's constantrefusal has made the parents give up.

The perspectioe of the caregioers:As caregivers, we stress the impor-tance of eating structured, cookedmeals. When an adolescent behavesthis way, he or she is working againstour treatment plan. The adolescentmust be asked about willingness tochange habits so as to promote weightnormalization—in other words, aboutmotivation for change. One way toincrease the motivation of the adoles-cent is to provide information aboutwhy it is better to eat cooked food atregular times every day. In this case,we propose that the parents actuallyact in an authoritarian way. if, dayafter day, the adolescent refuses to eatthe dinner, the parents may have toforbid the adolescent from eating

sandwiches and the adolescent mayhave to go hungry instead. Althoughthis would give rise to conflict, a con-flict that stops behavior that counter-acts everyone's desires can be worth-while.

Case 7: Indifferent parentingmodel. The seventh and final caseillustration is meant to be atmlyzedand worked through by the teamalone. This probtem sometimes arisesin parents of adolescents with obesity.

Jenny, 11 years old, has a BMI of33. extreme obesity for her age. SheHues with her biological mother andfather and is an only child. The pro-fessional team is rinding it difficult toget Jenny and her parents to make thenecessary changes to stop her acceler-ated weight gain. After having metwith the family a couple of times. Ithas become clear that the mother hasa serious alcohol addictiori.Forturiately. she is already In a thera-py program and getting help. Jenny'smother feels extremely guilty for hav-ing neglected Jenny for a lor\g time.Her parenting role is related to com-pensating for her long periods of alco-hol abuse, and thus she is quite per-missive. The team then turned to thefather, to ask him to provide the struc-tute in tiie home, but he refused. He isunwilling to make any change thatincludes him. His strategy has been toescape alt the problems by workinglate or going with friends to sportingevents. He will not listen to the team'srequests to be more supportive ofJenny. He clearly seems indifferent toJenny's needs. The only positive signof change is that Jenny's weight gainhas become a little bit slower than itwas before the family entered the obe-sity treatment program. Tiie team hasto deal with a family situation inwhich there will be little if any sup-port from the parents. How can theteam support Jenny and her parents?

The perspective of the caregioers:Many treatment programs for adoles-cents with obesity exclude families inwhich the parents show no motivationto participate. The absence of motiva-tion can be attributable to indifferenceor major personal problems. If thesefamilies could be included in treat-ment programs, their adolescentswould have access to the supportfrom the health care team that theylack from their own parents. A child'sright to adequate health care is notnegotiable, even when their parentsare not supportive.

Thus, supporting the parents intheir parenting role is the first optionand must be given to the parents bytrying to meet with them several times

and to keep a dialogue in an openatmosphere to give the parents theopportunity to help their child. If, inspite of this there is no sign of compli-ance from the parents then, accordingto Swedish law, caregivers have toreport cases like this to the socialauthorities, in the best interest of thechild and in agreement with the UnitedMations (UN) convention on the rightsof the child.

Nursing ImplicationsAdolescent obesity has serious

consequences in terms of globalhealth. The primary aim of treatingadolescents with obesity is to stop fur-ther weight acceleration and in thelong run try to normalize the weight.Realizing this objective calls for con-sistent efforts to choose healthylifestyle alternatives. Adolescents withobesity must receive support fromparents and adults in their environ-ment to become competent and moti-vated to choose healthy eating- andphysical activity patterns. Caregiversplay an important role in educatingand motivating the adolescents.However, parents are key persons inthe treatment of adolescents with obe-sity, both as models for a healthychoice of food and physical activityand for changing adolescent habits.Recognizing different parenting stylesis important. Pediatric nurses andother health professionals can supportparents by explaining the effect of dif-ferent parenting models and teachingthem parenting skill techniques. Byusing case illustrations and models forparenting styles, caregivers can helpparents to be more involved andengaged to participate actively intreatment.

ReferencesBarlow, S.E., & Dietz, W.H. (2002).

IVIanagement of child and adolescentobesity: Summary and recommen-dations based on reports from pedia-tricians, pediatric nurse practitioners,and registered dietitians. Pediatrics,7 70,236-238.

Baumrind, D. (1971). Current patterns ofparental authority. DevelopmentalPsychology Monograph. 4 (1:2).Birmingham, AL: The AmericanPsychological Association.

Berg-Kelly, K. (1998). Ungdomsmedicin.Stockholm: Liber AB.

Brownell, K.D., Kelman, J.H., & Stunkard,A.J. (1983). Treatment of obese chil-dren vi/ith and without their mothers:Changes in weight and blood pres-sure. Pediatrics, 77, 515-523.

Centers for Disease Control andPrevention. (2005, September). BMI-Body Mass Index: BMI for children

PEDIATRIC NURSING/Janaury-February 2007/Vol. 33/No.

and teens. Retrieved September 30,2005 from http://www.cdc.gov/nccd-php/dnpa/bmi/bmi-for-age.htm

Cole, TJ., Bellizi, M.C., Flegal, K.M., &Dietz, W.H. (2000). Establishing astandard definition for child over-vweight and obesity worldwide:International survey. British MedicalJournat, 320. 1240-1243.

Ebbeling, C, Pawlak, B., & Ludwig, D.(2002). Childhood obesity: Publichealth crisis, common sense andcure. Lancet, 360, 473-482.

Egger, G., &Swinburn, B. (1997). An "eco-logical" approach to the obesity pan-demic. British Medlcat Journal, 3t5.477-480.

Elkind, D. (1967). Egocentrism in adoles-cence. Chitd Deveiopment, 3fi(4),1025-1034.

Epstein, L.H. (1996). Family-based behav-ioural intervention for obese children.internationatJournat of Obesity, 20(1),14-21

Golan, M., & Crow, S. (2004). Targetingparents exclusively in the treatmentof childhood obesity: Long-termresults. Obesity Research, 12(2). 357-361.

Golan, M., & Weizman, A. (2001). Familialapproach to the treatment of child-hood obesity: Conceptual model.Journai of Nutrition Education, 33(2).102-107.

Gortmaker, S.L., Must, A., Perrin, J.M,Sobol, A.M., & Dietz, W.H. (1993).Social and economic consequencesof overweight in adolescence andyoung adulthood. The New EngtandJournat of Medicine, 329{M), 1008-1012.

Janssen, I., Katzmarzyk, P.T., Boyce, W.R,Vereecken, C, Mulvihill, C, Roberts,C, Currie, C, & Pickett, W. (2005).The Health Behavior in School-AgedChildren Obesity Working Group,Comparison of overweight and obe-sity prevalence in school aged youthfrom 34 countries and their relation-ship with physical activity anddietary patterns. Obesity Reviews, 6,123-32.

Maccoby, E.E., & Martin, J.A. (1983).Socialization in the context of thefamiiy: Parent-child Interaction. InP.H. Mussen, & E.M. Hetherington(Eds.), i-tandbook of child psycholo-gy: Vot. 4. Sociatization, personality,and sociai development (pp. MOI) .New York: John Wiley & Sons.

M^rild, S. (2006) Unpublished data.Neinstein L.S., Juliani, M.A., & Shapiro, J.

(1996). Psychosocial development innormal adolescents. In L.S. Neinstein(Ed.), Adolescent heatth care, A prac-tical guide [pp. 40-45). Los Angeles:Williams &Wilkins.

Schwimmer, J.B., Burwinkle, T.M., &Varni, J.W. (2003). Health-relatedquality of life of severely obese chil-dren and adolescents. JAMA. 289,14.

Sindeiar, H.A., Abrantes, A. M., Hart, C,Lewander, W., & Spirito, A. (2004).Motivational interviewing in pedi-atric practice. Current Problems inAdolescent Heatth Care, 34. 322-339.

Story, M.T., Neumark-Stzainer, D.R.,Sherwood, N.E., Holt, K., Trowbridge,F.L, & Barlow, S.E (2002). Manage-ment of child and adolescent obesity:Attitudes, barriers, skills and trainingneeds among health care profession-als. Ped/atr/cs, H0(1), 210-214.

Strauss, R.S. (2000). Childhood obesityand self-esteem. Pediatrics, 705(1),15.

Viner, R.M, & Cole. TJ . (2005). Adultsocioeconomic, educational, social,and psychological outcomes of child-hood obesity: A national birth cohortstudy. British Medicat Journat, 330.1339-1340.

World Health Organization (WHO). (2000).Obesity: Preventing and managingthe global epidemic. Report of aWHO consultation, technical reportseries 894. Geneva: World HealthOrganization.

_̂ Be A Hero _ , , ^Recommend Relief!

Diaper Rash Problems? Dr. Smith's Diaper Ointment®

Recommend

DR. SMITH'SDIAPER OINTMENTProblem Solved!

Easy to apply - easy to wash off' Creates an invisible, effectivebarrier to protect chafed skin,and seal out wetnessContains no steroid or antibiotic

'No unpleasant odor,or"globiness"

Another,

Product

Available at these and otherRetailers Nationwide

Dierbergs, Dillons,Discount Drug Mart, Eckerd,HEB, Price Chopper, Publix,Randalls,Tom Thumb,Walgreens. Limited Kroger& Wal-Mart stores.Ask a store manager for availability.

For samples or information, call 1-800-434-BETA (2382)orvrsit our website: www.beta-derm.com DERMACEUTICALS, INC,

PEDIATRIC NURSING/Janaury-February 2007/Vol. 33/No.