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Providers' Involvement of Blended Families in Pediatric Weight Management Programs.

One-third of children in the United States are overweight or obese (Ogden, Carroll, Kit, & Flegal, 2014), and are at risk for developing chronic health conditions (Crossman, Sullivan, & Benin, 2006; Franks, Hanson, Knowler, Sievers, Bennett, & Looker, 2010; Must et al., 1999). Parents and family members have important roles in the prevention and treatment of pediatric obesity, and past evidence has confirmed intervening with families provides more sustainable dietary and physical activity changes for children (Berge & Everts, 2011; Kitzman-Ulrich et al., 2010). In 2007, the Expert Committee Recommendations Regarding the Prevention, Assessment, and Treatment of Child and Adolescent Overweight and Obesity described care for children in pediatric weight management programs (PWMPs), with an emphasis for treatment to be family based (Barlow & the Expert Committee, 2007; O'Conner et al., 2017). Over half of first marriages ending in divorce in the United States, and approximately 75% of those who divorce decide to remarry (Centers for Disease Control and Prevention, 2017). Further, over half of children under age 13 are part of a blended family (American Psychological Association, 2018b). Blended families are families that are formed when remarriage occurs or when children living in a household share one or no biological parents, and may include the presence of a stepparent, stepsibling, or half-sibling (Kreider, 2007). Given the high incidence of parental divorce, remarriage, and of children living in blended families, PWMPs will undoubtedly be treating youth who are part of blended families and who may be sharing time between two household residences (as seen in split, joint, and shared custody arrangements). However, guidance for involving blended families (i.e., step families) and the families of youth who share time between multiple households (referred to as multiple households herein) in treatment is not addressed.

Children in blended families or multiple households are faced with unique challenges that can affect their diet, physical activity, and ultimately weight status. For example, children who experience parental divorce are more likely to have overweight or obesity and poorer eating behaviors (Biehl et al., 2014; Yannakoulia et al., 2012). Further, those children with mothers who remained repartnered or remained single had additional increases in body mass index (BMI; Schmeer, 2012). There is also evidence to suggest that children who do not live with their two biological married parents have greater odds of having obesity (Augustine et al., 2013). Although there is some data detailing the risk of obesity and negative dietary changes among children who experience parental divorce, there is essentially no information available about children who resided in multiple homes, often due to custody arrangements.

Children sharing time between multiple households may face increased challenges in treatment, where their goals and treatment plans need to be shared and coordinated between households. Depending on the family dynamics between households, this could present challenges. The first part of a National survey by Pratt and colleagues (2018) assessed how providers in PWMPs involve family members, experience barriers to family involvement, and address challenging family dynamics (Pratt, Skelton, Eneli, Collier, & Lazorick, 2018). The most common challenging family dynamic reported by providers was parental divorce and separation. Given that one of the biggest complaints of step families is not having access to the same resources or information as the child's primary caregiver (The Step Family Foundation, 2018), it is important to assess how providers working in PWMPs are currently involving blended families and multiple households (Carr & Springer, 2010). This information is essential to have before determining how practice guidelines may need to be adapted, and before further inquiry is done with blended families and multiple households.

At present, there are no guidelines for providers to follow for the assessment and treatment of blended families and multiple households in PWMPs, and there is scare literature addressing these family structures in treatment. The research that has been conducted relevant to the family structure of children in PWMPs tends to focus on single and two-parent family structures, not differentiating between two-parent structures that contain step parents or biological parents, where children in single parent (mostly single-mother) homes have higher rates of overweight and obesity than children living in two-parent homes (Augustine et al., 2013; Huffman, Kanikireddy, & Patel, 2010; Schmeer, 2012). Informed by Family Systems Theory (Bertalanffy, 1952; Pratt & Skelton, 2018), the objective of this study is to describe how providers report involving blended families and multiple households in PWMPs. This study is the first step toward understanding PWMP providers' current treatment of youth in blended families and those sharing time between multiple households, which is essential to know before determining if tailored interventions are needed for these families, and before further assessment of these families' needs in PWMPs.

Method

Subjects

Providers currently employed in PWMPs centers or clinics were invited to participate in a one-time electronic Qualtrics survey. Recruitment methods are previously described (see Pratt, Skelton, Eneli, Collier, & Lazorick, 2018). Three listservs were used to contact potential participants: The Obesity Society's (TOS) Clinical Treatment and Pediatric Obesity listservs, and the Children's Hospital Association (CHA) listserv. The survey invitation was posted twice on all three listservs. Inclusion criteria were that providers should be currently employed within a PWMP center or clinic and actively working with youth and/or families in this capacity. Providers needed to be located in the United States or Canada and were not limited to profession so long as they were provided direct clinical care, not administrative. More than one provider at each treatment center or clinic could participate in the survey. A total of 85 participants assessed the survey and were provided with gift cards. Of those 85, there were 71 unique and complete participant responses, and 47 unique centers/clinics that participated. The survey was approved by the Ohio State University's institutional review board (IRB) in Columbus, Ohio.

Procedure

Participants were provided a description of the study, investigators' contact information, inclusion criteria, and a link to the survey. The initiation of the survey included an initial question affirming consent. Following the brief 20-min survey, participants were presented with an option for a $10 retail gift card.

Survey

The survey included questions on participants' background and their center/clinic model, inclusion of family members in treatment, barriers to family inclusion, and challenging family dynamics experienced in treatment (see Pratt et al., 2018). For this brief report, we detail the six exploratory questions pertaining to blended families (see Table 1).

Analysis

Descriptive statistics were used to report results both at the participant and center/clinic-level. Open-ended questions were coded by two authors (JS and KP), using content analysis to produce frequencies and percentages for participant responses within each open-ended question. After reading through the open-ended answers, a codebook was developed that the two coders used. Disagreements in coding were handled by triangulating in an additional investigator (SL). Following coding, common codes within each question were organized into categories that were consolidated into themes. Providers' free text may have been coded multiple times for different themes; hence, the number of providers who responded is not equal to the sum of frequencies in each open-ended question. Interrater reliability for the two coders was 96%.

Results

There were 71 providers who participated, representing 47 centers/clinics in the United States and Canada. Seven out of 71 participants did not provide the name of their clinic/center but were included in analyses at the provider level. Providers selected their discipline from a list and were allowed to select more than one (i.e., RN and RD). Participants identified as medical (pediatrician, MD, nurse practitioner, RN; n = 51), allied health (dietitian, physical therapists, exercise physiologist, etc.; n = 29), specialty (i.e., Diabetologist, Surgeon, Gastrologist; n = 11), and/or mental and behavioral health (licensed clinical/child psychologist, licensed clinical social worker, licensed marriage and family therapist, etc.; n = 13) providers. Using the stages of care provided by the Expert Committee Recommendations Regarding the Prevention, Assessment, and Treatment of Child and Adolescent Overweight and Obesity (see Barlow & the Expert Committee, 2007), the majority of participants reported that their center/clinic conducted stage 3 or 4 care, which is more intensive, frequent, comprehensive, and includes a multidisciplinary team (stage 3 n = 24, 34%; stage 4 n = 29, 41%). Stage I (n = 4, 6%) and stage 2 (n = 14, 20%) care were less common, and typically take place in primary care often treating overweight with the goal of preventing obesity.

The majority of providers reported assessing the multiple households that the patient resides in (yes n = 67, 96%), most often during their collection of a medical history (yes n = 46, 65%), while setting goals (yes n = 37, 54%), and within the intake paperwork (yes n = 35, 49%). Six participants selected "other," which included the write-in responses: "when assessing environment," "during the interview," "when talking about barriers/strengths," and "when appropriate to the conversation."

Providers most frequently reported including the primary caretakers of youth at all known households (yes n = 42, 59%; see Table 2). However, providers did not include youths' immediate family members, like siblings, at their primary household (yes n = 5, 1%), more than one household (yes n = 12, 17%), or all known households (yes n = 18, 25%). Providers also reported lack involvement of other family members/caretakers, like aunts/uncles, who are not immediate family members regardless of shared residence: at one residence (yes n = 4, 1%), more than one residence (yes n = 11, 15%), and at all known residences (yes n = 23, 32%).

Most providers reported adapting dietary (yes n = 60, 88%) recommendations to accommodate more than one household. In the open-ended question about how dietary recommendations were adapted, 54 providers responded. The most frequent themes reported were: goals are made separately for each family/household (n = 17); adjustments were made on a per patient or family basis (n = 12) and; materials (extra copies, written goals, etc.) were provided to all family members in attendance and those not there (n = 9). Other themes reported at lower frequencies included: the Dietitian is responsible for making these adjustments (n = 6); all family members/caregivers are encouraged to attend the visit (n = 6) and; separate appointments or assessments are conducted for each family/household (n = 6).

Providers also reported adapting physical activity (yes n = 53, 77%) recommendations to accommodate more than one household. In the open-ended question about how physical activity recommendations were adapted, 49 providers responded. The most frequent themes reported included: Goals were made separately for each family/household (n = 16); Adjustments were made based on the resources of each family/households (n = 15) and; Adjustments were made based on the physical space and environment at each household (n = 11). Other themes reported at lower frequencies included adjustments that were made based on safety (n = 6) or were made on a per patient or family basis (n = 6).

Providers reported (n = 62) the most frequent challenges they experienced in extending the patients' treatment plan and goals to multiple households included: One caregiver/household not willing to participate or make changes (n = 21); Inconsistency between households (n = 14); One caregiver/household not present at visits (n = 12) and; Fighting between parents and grandparents (n = 9). Other themes reported at lower frequencies included blaming one caregiver/household for child's weight and unhealthy behaviors (n = 7); time and resources for separate household assessments and appointments (n = 6); communication between households (n = 5); Financial and economic resources differ between households (n = 5); communicating with the non-attending caregiver/household (n = 5) and; one caregiver/household is not concerned with the child's weight (n = 4). See Table 3 for example quotations for each theme.

Despite providers reporting that they assess multiple households when a child is part of a blended family, most reported not having an interview guide, template, or form to use in their assessment (yes n = 19, 27%).

Discussion

Providers in PWMPs recognize the challenges that blended families present to patient engagement, providers' time, and clinic protocols in pediatric weight management. Overall, providers reported that they attempted to include all caregivers in blended families and multiple households in treatment. This was an unexpected finding, given that prior research on providers in PWMPs noted that parental divorce and separation was the most common challenging family dynamic that they experienced, and often had to refer to behavioral health providers for this dynamic (Pratt et al., 2018). Additional information about providers' methods of engaging caregivers in multiple homes is needed. It may be that providers methods of engagement (frequency, depth of information, etc.) differ based on how much time the child spends with each caregiver, where noncustodial caregivers may be engaged but engaged less than custodial caregivers.

Providers did report making some adaptations to their recommendations for dietary and physical activity goals when a caregiver from one household was absent from the visit. Further, they reported that challenges arose in translating these goals to the nonattending caregiver and involving them in ongoing treatment. Another challenge noted was accommodating blended families and multiple households with existing clinic space and scheduling limitations, especially for families who prefer not to be in the same room with one another. Despite providers' assessment of blended families and multiple households, they reported not having a formal template, guide, or protocol for how to include these families. The variability in how providers adapted dietary and physical activity goals for blended families and multiple households, and the challenges they noted during encounters with blended families, may indicate that new approaches are needed to assess and engage these families throughout the treatment process.

With over half of U.S. first marriages ending in divorce, and even greater odds of subsequent marriages ending in divorce, it is likely that a majority of children seen in PWMPs will be part of blended families or have care coordinated across multiple households. These families are likely going through transitions that further complicate their behavioral goals, as they determine new roles and responsibilities in the family. Transitions may include living arrangements that need to be negotiated among adults, exploring feelings and concerns of adults and children about the dissolved union, and making new parenting decisions - including step parent roles. Further, these transitions, particularly negotiating parenting changes and decisions, are likely to affect the patients' weight management goals. Researchers have shown that nonparticipating family members notice changes in how the child and family functions when a child is participating in a PWMP (Bishop, Irby, & Skelton, 2015); if family members are unaware of the patient's goals, they are unable to support, and may even hinder progress. For example, if a stepparent assumes responsibility over snack and meal preparations but is not aware of the child's weight management goals, s/he may inadvertently be hindering the child's success at behavior change. Additionally, parents may parent biological children different from step siblings or half-siblings who live in the home. Often in family therapy with blended families, mental/behavioral health providers work to help coordinate parenting efforts between families to keep them focused on the child's adjustment and progress (American Psychological Association, 2018a). In PWMPs, such coordination is likely needed to help focus parents/caregivers on the ultimate goal of keeping their child healthy. Further research should determine what the needs are of blended families in PWMPs, and how to tailor treatment approaches based on the transitions blended families face, while remaining focused on weight management goals.

Future research should aim to assess the perspectives of blended families about their experience in PWMPs, and from perspective about the challenges, barriers, and inclusion in treatment. Assessing youth and family members' perspectives will provide valuable evidence that may be congruent with what providers experienced or provide new insight into ways treatment methods may need to be adapted. Additionally, researchers should ways to include family structure in their assessment, beyond single-and two-parent structures, in order to determine if youth in blended families and multiple households have different outcomes in PWMPs compared to those youth in families with other structures. The long-term goal of this work should be to find ways to both mitigate the obesity risk for youth who experience parental divorce, and to lead to better outcomes in PWMPs.

Limitations

One strength of the study is that the survey was nationally distributed through three different listservs to providers working in PWM centers/clinics. However, based on this form of recruitment, it is not possible to obtain a response rate, since the number of individuals at any given point fluctuates on these listservs. This sampling strategy limits the generalizability of findings presented herein. Given the lack of research on blended families in PWMPs, there were not any validated survey measures that the authors could use to assess challenges with and involvement of blended families and multiple households in PWMP. Thus, nonvalidated investigator-created questions were utilized limiting the validity of findings. It is also possible that there are other important aspects of blended families that were not captured in the investigator-created questions. Finally, this study only sampled providers working in PWMPs. Future work should seek to validate the findings noted herein with youth and families seen at PWM centers/clinics.

Summary

The purpose of this survey was to understand what is happening, descriptively, with respect to involvement of blended families and multiple households, and challenges with involvement in PWMPs. Providers recognize the complexity of families and diversity in family structures, particularly those children who spend time in blended families and multiple households. Greater emphasis and study of diverse family structures is needed to develop nuanced approaches for the prevention and treatment of childhood obesity. This research is the first step toward understanding how providers are currently treating youth in blended families and in multiple households in PWMPs. This is an essential step needed to determine how practice guidelines may need to change, and how the needs of blended families and multiple households can be assessed with knowledge of current PWMP provider practices.

References

American Psychological Association. (2018a). Making stepfamilies work. Retrieved from https://www.apa.org/helpcenter/stepfamily.aspx

American Psychological Association. (2018b). Marriage and divorce. Retrieved from https://www.apa.org/topics/divorce/

Augustine, J. M., & Kimbro, R. T. (2013). Family Structure and Obesity Among U.S. Children. The Journal of Applied Research on Children, 4, 1-24.

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Berge, J. M., & Everts, J. C. (2011). Family-based interventions targeting childhood obesity: A metaanalysis. Childhood Obesity, 7, 110-121. http://dx.doi.org/10.1089/chi.2011.07.02.1004.berge

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Bishop, J., Irby, M. B., & Skelton, J. A. (2015). Family Perceptions of a Family-Based Pediatric Obesity Treatment Program. Infant, Child, & Adolescent Nutrition, 7, 278-286.

Carr, D., & Springer, K. W. (2010). Advances in families and health research in the 21 st century. Journal of Marriage and Family, 72, 743-761. http://dx.doi.org/10.1111/j.1741-3737.2010.00728.x

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Crossman, A., Sullivan, D. A., & Benin, M. (2006). The family environment and American adolescents' risk of obesity as young adults. Social Science & Medicine, 63, 2255-2267. http://dx.doi.org/10.1016/j.socscimed.2006.05.027

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Kitzman-Ulrich, H., Wilson, D. K., St. George, S. M., Lawman, H., Segal, M., & Fairchild, A. (2010). The integration of a family systems approach for understanding youth obesity, physical activity, and dietary programs. Clinical Child and Family Psychology Review, 13, 231-253. http://dx.doi.org/10.1007/s10567-010-0073-0

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Pratt, K., & Skelton, J. (2018). Family functioning and childhood obesity treatment: A family systems theory-informed approach. Academic Pediatrics, 18, 620-627. http://dx.doi.org/10.1016/j.acap.2018.04.001

Pratt, K. J., Skelton, J. A., Eneli, I., Collier, D. N., & Lazorick, S. (2018). Providers' involvement of parents, families, and family dynamics in youth weight management programs. Global Pediatric Health, 5. Advance online publication. http://dx.doi.org/10.1177/2333794X18817134

Schmeer, K. K. (2012). Family structure and obesity in early childhood. Social Science Research, 41(A), 820-832. http://dx.doi.org/10.1016/j.ssresearch.2012.01.007

The Step Family Foundation. (2018). Stepfamily statistics. Retrieved from www.stepfamily.org

Yannakoulia, M., Papanikolaou, K., Hatzopoulou, I., Efstathiou, E., Papoutsakis, C, & Dedoussis, G. V. (2012). Assocications between family divorce and children's BMI and meal patterns: The GENDAI Study. Obesity, 16. Advance online publication.

Received February 15, 2019

Revision received August 13, 2019

Accepted September 6, 2019

Keeley J. Pratt, PhD

The Ohio State University

Ihuoma Eneli, MD

Nationwide Children's Hospital, Columbus, Ohio, and The Ohio State University

Suzanne Lazorick, MD

East Carolina University

David N. Collier, MD

East Carolina University

Joseph A. Skelton, MD, MS

Wake Forest School of Medicine, Winston-Salem, North Carolina

Keeley J. Pratt, PhD, Department of Human Sciences, College of Education and Human Ecology, The Ohio State University; Suzanne Lazorick, MD, Departments of Pediatrics and Public Health, Brody School of Medicine, East Carolina University; Ihuoma Eneli, MD, Nationwide Children's Hospital, Center for Healthy Weight and Nutrition, Columbus, Ohio, and Department of Pediatrics, The Ohio State University; David N. Collier, MD, Department of Pediatrics, Brody School of Medicine, East Carolina University; Joseph A. Skelton, MD, MS, Department of Pediatrics, Wake Forest School of Medicine, Winston-Salem, North Carolina.

We would like to acknowledge Oliva (Zimmer) Wolever for assistance with developing questions specific to blended families.

Correspondence concerning this article should be addressed to Joseph A. Skelton, MD, MS, Department of Pediatrics, Wake Forest School of Medicine, Winston-Salem, NC 27157. E-mail: jskelton@wakehealth.edu

http://dx.doi.org/10.1037/fsh0000446
Table 1
Survey Questions Asked Blended Families and Multiple Households in PWMPs

1. When working with patients in blended families (separated, divorced,
      remarried, etc.), do you assess the multiple households that
      patients may be residing in? For example, different residential
      or non-residential custody arrangements or overnight
      childcare. (YES/NO)
   If YES: When do you assess this? (check all that apply) During:
      [] intake paperwork
      [] medical history
      [] goal setting
      [] other:_____(please write in)
2. When children live at more than one household, whom do you include
  in treatment goals? (check all that apply) primary caretaker at:
      [] one residence
      [] more than one residence
      [] and all known residences
  immediate family members at:
      [] one residence
      [] more than one residence
      [] and all known residences
  other family members at:
      [] one residence
      [] more than one residence
      [] and all known residences
3. Do you adjust dietary recommendations for multiple households?
   (YES/NO)
   If YES: How do you adjust dietary recommendations for multiple
   households? (open-ended)
4. Do you adjust physical activity recommendations for multiple
   households? (YES/NO)
   If YES: How do you adjust physical activity recommendations for
   multiple households? (open-ended)
5. Please describe some of the challenges you have experienced in
   extending the patient's treatment plans and goals to multiple
   households? (open-ended)
6. Do you have an interview guide, template, or form that you use to
   include blended families or multiple households in patients' goals
   and treatment planning? (YES/NO)

Table 2
Blended Families/Multiple Households/Blended Inclusion in Treatment
Goals (n = 71) [N (%yes)]

When children live at more than one              One
   household/blended families, whom
   does center/clinic include in                Residence
   treatment goals?


             Primary caretaker at                19 (27%)
             Immediate family members at          5 (1%)
             Other family members/caretakersat    4 (1%)

When children live at more than one             More than One  All Known
   household/blended families, whom
   does center/clinic include in                 Residence    Residences
   treatment goals?

             Primary caretaker at               25 (35%)       42 (59%)
             Immediate family members at        12 (17%)       18 (25%)
             Other family members/caretakersat  11 (15%)       23 (32%)

Table 3
Open-Ended Responses to Challenges Experienced When Extending Treatment
Plans and Goals to Multiple Households (n = 62)

Theme                                  Frequency (*)

One caregiver/household not willing      21
  to make changes or participate
Inconsistency between households         14
One caregiver/household not present      12
  at visit
Fighting between                          9
  parents/grandparents
Blaming one parent for unhealthy          7
  behaviors/child's weight
Time for separate appointments            6
Communicating with non-attending          5
  caregiver/household
Financial/economic factors, resources
  differ between households               5
Communication between households          5

One caregiver/household is not            4
  concerned about child's weight

Theme                                  Example

One caregiver/household not willing    One caregiver unwilling to
  to make changes or participate         participate in setting goals
                                         or making changes in either
                                         nutrition or exercise.
Inconsistency between households       Limit setting varies; different
                                         daily routines.
One caregiver/household not present    If one caregiver is not present,
  at visit                               we have to rely on the patient
                                         or other caregivers'
                                         self-report, which may not be
                                         accurate.
Fighting between                       Fighting between divorced
  parents/grandparents                   parents; grandparents
                                         undermining parents.
Blaming one parent for unhealthy       Blaming the other parent for
  behaviors/child's weight               having high calorie foods/fast
                                         food, etc.
Time for separate appointments         Time consuming to build two
                                         separate plans/goal sheets.
Communicating with non-attending       Participation of family members
  caregiver/household                    that do not attend clinic and
                                         relying on communication of one
                                         caregiver to another.
Financial/economic factors, resources
  differ between households            Situations and resources often
                                         vary between households.
Communication between households       Conflict and difficulty
                                         communicating about goals and
                                         plans between households.
One caregiver/household is not         One caregiver does not believe
  concerned about child's weight         that there is a health problem
                                         with the child's weight.
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Article Details
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Title Annotation:BRIEF REPORT
Author:Pratt, Keeley J.; Eneli, Ihuoma; Lazorick, Suzanne; Collier, David N.; Skelton, Joseph A.
Publication:Families, Systems & Health
Article Type:Survey
Geographic Code:1U5NC
Date:Dec 1, 2019
Words:4512
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