Children and Youth Services Review 32 (2010) 833–839

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Behavioral characteristics among obese/overweight inner-city African AmericanChildren: A secondary analysis of participants in a community-based Type 2 diabetesrisk reduction program

Susan Stone a,⁎, Aarthi Raman b, Sharon Fleming b

a School of Social Welfare, University of California at Berkeley, 120 Haviland Hall, Berkeley, CA 94720, United Statesb Robert C and Veronica Atkins Center for Weight and Health, Department of Nutritional Sciences and Toxicology, University of California at Berkeley, 119 Morgan Hall, Berkeley,CA 94720, United States

⁎ Corresponding author. Tel.: +1 510 643 6662.E-mail address: sistone@berkeley.edu (S. Stone).

0190-7409/$ – see front matter © 2010 Elsevier Ltd. Aldoi:10.1016/j.childyouth.2010.02.002

a b s t r a c t

a r t i c l e i n f o

Article history:Received 4 June 2009Received in revised form 2 February 2010Accepted 5 February 2010Available online 11 February 2010

Keywords:Childhood obesityCommunity interventionBehavioral outcomes

This secondary analysis presents psycho-social characteristics of two cohorts of overweight/obese AfricanAmerican children [baseline (n=68) and post-intervention (n=81)] participating in a community-based,year-long Type 2 diabetes prevention program. The original intervention was designed to incorporatestrategies that existent literature deemed most promising with respect to obesity intervention and reductionof Type 2 diabetes risk. Eligible children were assigned to one of two sites and a random process was thenused to designate the two sites as either treatment or control. To add to the literature on the psycho-socialprofiles of overweight children, this analysis considers child and parent caregiver ratings derived from theBehavioral Assessment System for Children, Second Edition-2 (BASC-2; Reynolds & Kamphaus, 2002). Forpurposes of reference, we index our findings to pre-intervention BASC-2 scores in the baseline cohort as wellas to scores of obese children previously reported by others. Parent-reported post-intervention scoresfavored the intervention condition on three of the four key composites including behavioral symptomsindex, internalizing problems and adaptive skills. However, child-reported outcomes showed fewer effects.

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© 2010 Elsevier Ltd. All rights reserved.

1. Introduction

Approximately 20% of children and adolescents are overweight orobese (Centers for Disease Control, 2004; Ogden, Carroll, Curtin,McDowell, Tabak, & Flegal, 2006). Affected children are at substantialrisk for a host of associated short and long term health complications(for reviews, see Ebbeling et al., Pawlak, & Ludwig, 2002; Must &Strauss, 1999). Of particular concern is the significant elevation in riskfor Type 2 diabetes (Rosenbloom, 2002). Indeed, rising rates of Type 2diabetes among children and adolescents is largely attributed toconcomitant growth in rates of childhood obesity (Ebbeling et al.,2002; Rosenbloom, 2002). Rates of childhood overweight and obesityvary disparately by race/ethnicity — a significantly larger percentageof African Americans and Latinos are overweight or obese comparedto White youth (Holtby et al., 2006). In addition, lower family socio-economic status and poorer neighborhood quality are associated withincreased risk of obesity and/or its comorbidities (Ebbeling et al.,2002; Lumeng, Appugliese, Cabral, Bradley, & Zuckerman, 2006).

In addition to increased risk of morbidity and mortality, well-controlled studies of children and adolescents who are overweight or

obese find that they exhibit greater levels of psychological distressrelative to peers within normal weight ranges (see Ebbeling et al.,2002). Given such evidence of psychological distress, it is surprisingthat there are few interventions that consider together the overallhealth (i.e. salient anthropometric and gluco-regulatory measures),health-related behaviors (nutritional and physical activity habits),and psychological functioning of affected children and adolescents,although such a multi-pronged intervention strategy has beenrecommended (Barlow & Dietz; 2002; Eliadis, 2006; Hines & Dietz;1994; Panzer, 2006; Tershakovec, 2004).

To begin to fill this notable gap in the literature, the current studyrepresents a secondary analysis of data generated from two cohorts ofinner-city, overweight/obese African American children enrolled in acommunity-based, Type II diabetes prevention program — one cohortevaluated at baseline and one cohort evaluated following one year ofenrollment in either the control or treatment groups to assess thepsycho-social profiles of participants, and to explore, post-hoc, whether childrenin the intervention condition showed favorable behavioral characteristics.Although the original intervention study targeted health and health-related indicators, it provides a ripe opportunity for secondary analysis,given that data were collected on child psycho-social functioning. Thissecondary analysis, in summary, provides an opportunity (1) to assessparticipant behavioral profiles and (2) generate exploratory findingsrelated to potential intervention effects on behavior. It was expected that

834 S. Stone et al. / Children and Youth Services Review 32 (2010) 833–839

several of the original program elements – e.g., a focus on key social-cognitive skills – could plausibly influence child behavioral outcomes, inaddition to the overall health and health-related behavioral indicatorstargeted by the original intervention.

2. Psycho-social correlates of child overweight and obesity

Controlling for key confounding factors (e.g., age, race, socio-economic status, key parental health characteristics and parentingpractices), children who are overweight or obese show higher levelsof psychological distress and problem behaviors than their counter-parts within a normal weight range (Braet, Mervielde, & Vander-eycken, 1997; Datar & Sturm, 2006; Lumeng, Gannon, Cabral, Frank, &Zuckerman, 2003). Specifically, overweight children report low levelsof self-esteem (French, Story, & Perry, 1995; Miller & Downey, 1999;Strauss, 2000), poor self concept (Davison & Birch, 2001), and highlevels of body dissatisfaction (Schwartz, Phares, Tantleff-Dunn, &Thompson, 1999). Child and adolescent bodyweight positively relatesto various indicators of depressed mood (Falkner et al., 2001; Pesa,Syre, & Jones, 2000). Relative to normal weight peers, overweightchildren are more likely to exhibit clinically significant behavioralproblems on a broad-band (i.e., including both internalizing andexternalizing symptoms) symptom composite (Lumeng et al., 2003).There is also evidence of a link between obesity and Attention-Deficit/Hyperactivity Disorder (Cortese et al., 2008).

There are at least three mechanisms that likely contribute toaffected children's elevated psycho-social distress. One mechanism isthrough shared risk factors for both obesity and other health andbehavioral problems. Poor and minority children, as well as thoseexperiencing risky family backgrounds (i.e. poor parental health andmental health, and harsh and/or inconsistent parenting practices) areat elevated risk for both obesity and behavioral problems (Brooks-Gunn & Duncan, 1997; Ebbeling et al, 2002; Evans, 2004; Lissau &Sorenson, 1994; Lumeng et al., 2003; Must & Strauss, 1999; Repetti,Taylor, & Seeman, 2002). A second plausible mechanism suggests thatbecoming overweight is associated with subsequent behavior pro-blems (Datar & Sturm, 2006; Lumeng et al., 2003). Such growth inproblems may be related to peer (via teasing, rejection; Hill & Silver,1995; Janicke et al., 2007), health provider (Teachman & Brownell,2001), educator, and larger social stigma-related processes (see Puhl& Latner, 2007). Third, there is also growing evidence that normalweight children with behavior problems are themselves more likelyto become overweight at later points in youth and adulthood(Lumeng et al., 2003; Pine, Goldstein, Wolk, & Weissman, 2001).

The extent to which there is a particular patterning of psycholog-ical distress among children who are overweight or obese as well asthe severity and clinical significance of this distress, however, is moredifficult to ascertain, given attributes of the current literature. First,research on childhood overweight and obesity is generally bifurcatedacross medical/health and mental health literatures, such that health-related and psycho-social variables are often considered separately.Second, studies that do consider the overlap between child over-weight and psychological distress typically utilize different behavioralmeasures and sample children over different age ranges, making itdifficult to compare and interpret psycho-socially-related findings.

There appears, moreover, to be a great deal of subgroup heteroge-neity in the associationbetween child overweight and specificmeasuresof psychological distress. Obese children presenting for weightmanagement treatment show greater levels of mental health impair-ment relative to their counterparts who do not present for treatment(Braet et al., 1997, Zeller, Saelens, Roehrig, Kirk, & Daniels, 2004). Age,sex, aswell as condition onset and timing also appear to have importantmoderating influences. The relationship between overweight andpsychological distress, for example, may be stronger for older versusyounger children and in girls versus boys (Datar & Sturm, 2006). Amonga national sample of children followed between kindergarten and third

grade, only children who became obese during the time period showedelevated levels of internalizing and externalizing symptoms (Datar &Sturm, 2006). Similarly, in a longitudinal, national sample of adolescentsassessed using the Center for Epidemiological Studies Depression Index(Goodman & Whitaker, 2002), the baseline correlation between beingoverweight and having a depressedmoodwas not significant. However,adolescents who became or remained overweight were more likely toreport depressed mood at subsequent data collection timepoints. It ishypothesized that racial/ethnic background may moderate the associ-ation between overweight and psychological distress, but findings aremixed (Datar & Sturm, 2006; Young-Hyman, Schlundt, Heman-Wenderoth, & Bozylinksi, 2003). Finally, reporting source may matteras well. Zeller et al.'s (2004) sample of obese children presenting forweight management treatment found that parent reports were morelikely to indicate clinically significant impairment than those of theirchildren.

3. Obesity-related prevention and intervention approaches

While increasing physical activity and decreasing caloric intakerepresent the so-called “common sense” approach to both obesityprevention and intervention strategies (Ebbeling et al., 2002), there isstill a paucity of research focused on children who are alreadyoverweight (Summerbell et al., 2003). The overall efficacy of interven-tions that have been assessed to date–delivered across a variety ofclinical, school and community settings–have been equivocal inachieving marked and sustained weight loss, especially over the longterm (Ebbeling et al., 2002; Summerbell et al., 2003, 2005). Suchprogramming, moreover, is characterized by high attrition and lowadherence rates. There is, however, growing consensus that interven-tion approaches need to emphasize increasing physical activity, utilizecognitive-behavioral techniques, target both children and their families,and consider contextual factors that support opportunities for regularphysical activity and healthy eating habits (Summerbell et al., 2005;Summerbell et al., 2003). Given evidence of social stigma towardschildrenwho are overweight, such interventionsmust alsomake effortsto avoid exacerbating these social processes (O'Dea, 2005). There is alsoan urgent need for programming to better attend to the psycho-socialcharacteristics of participants, as there has been little explicit consid-eration of psychological functioning of participants and that mostinterventions exclude children with significant psychological distress(Tershakovec, 2004).

Given the limitations of the current literature, the current secondaryanalysis assesses the baseline and (Cohort 1: sample of 68) and post-intervention (Cohort 2: sample of 81) behavioral characteristics of asample of overweight/obese African American children participating incommunity-based, year-long Type 2 diabetes prevention program asmeasured by child and parent reports on the Behavioral AssessmentSystem for Children, Second Edition-2 (BASC-2; Reynolds & Kamphaus,2002). The original intervention was designed to incorporate strategiesthat existent literature deemed most promising with respect tobehaviors associated with obesity-related intervention and preventionof its comorbidities (i.e. Type 2 diabetes). That is, the programwas longterm, focused on improving diet and increasing physical activity andwas strongly grounded within a cognitive-behavioral framework thatexplicitly included caregiver participation. Additionally, the programaimed to maintain self-esteem by focusing on healthy behaviors ratherthan on the need for weight loss.

In the early stages of program delivery, observations suggested thateffectiveness of program delivery was being negatively impacted by thepsychobehavioral status of the children. To address this, the interventioncomponents were modified to directly address self-awareness, the waysin which thoughts and feelings combine to influence behavior, and goalsettingwith respect to effective communication. As this aspectwas not inthe original program concept, the psychobehavioral characteristics ofCohort 1 were not assessed at baseline. Because cognitive-behavioral

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strategies show efficacy across a wide range of child psychologicalproblems, including both internalizing and externalizing symptoms(Weisz, Doss, & Hawley, 2005) as well as within obesity-relatedintervention, we hypothesized that overweight African Americanchildren who had been exposed to the treatment intervention wouldexhibit indicators of better psycho-social functioning as measured by theBASC-2 relative to peers exposed only to the control condition (Cohort 1).

As such, the current study is best understood as a secondary andpost-hoc analysis of data generated from the original interventionstudy. Given the limitations of current literature, we capitalized on theanalytic opportunity to gather post-test only comparisons onbehavioral profiles on the children participating in the interventionand control arms of the original study. To add to the literature on thepsycho-social profiles of overweight children, we examine function-ing across all available BASC-2 composites. For purposes of reference,we also index our findings to pre-intervention BASC-2 scores in asubsequent study cohort of overweight African American childrenwho were recruited for future participation in either the treatment orcontrol arms, but who had not yet been exposed to programming(Cohort 2; baseline condition; n=68 child-reported scores and n=50caregivers) as well as a related study of obese children performed byother researchers who also administered the BASC-2 instrument(Zeller et al., 2004) (Table 1).

4. Methods

4.1. Participants and data sources

The current study is a cross sectional, secondary analysis of resultsof BASC-2 ratings of child and caregiver participants in the TakingAction Together (TAT) study. Participants in the original study wererecruited from schools and other community organizations in twogeographically discrete, inner-city, low income and predominantlyAfricanAmerican regions of Oakland, California. In order to participate,children had to be between 9 and 10 years old and have a body massindex (BMI) greater than the 85th percentile (calculated from theCenters for Disease Control and Prevention (CDC) growth charts) atbaseline, and, based on prior research on obesity and Type 2 diabetesrisk, have at least one biological parent of African American ancestry.Childrenwere excluded if they had a systemic ormetabolic disorder orwere taking medication known to affect energy metabolism or bodyweight and or had a known condition that would preclude participa-tion in the program. The subject recruitment and selection process as

Table 1Characteristics of study participants.

Cohort 1 Cohort 2

Intervention Control Baseline

Mean (SD)

Participating adult family memberNumber evaluated 33 38 68Sex: % femalea 82.8 86.8 95.6Age 44.2 (11.7) 39.4 (7.4) 38.9 (10.7)Socio-economic status indexb 8.32 (1.8) 8.95 (1.6) 8.90 (1.6)

Participating childrenNumber evaluated 40 41 50Sex: % female 55.0 51.2 56.0Age 11.3 (0.8) 11.4 (0.9) 9.7 (0.7)BMI, kg/m2 30.2 (5.39) 29.0 (5.6) 26.4 (6.5)BMI z-scorec 2.13 (0.54) 2.06 (0.51) 1.97 (0.57)

a Of the female adult family participants, 87% were mothers/stepmothers, 9.5% weregrandmothers/great grandmothers; 3% were aunts/great aunts and 0.5% wereguardians. Of the male adult family participants, 84% were fathers/stepfathers, 10.5%were grandfathers and 5.5% were brothers.

b Index included education of participating adult family member, employment statusand housing type.

c BMI adjusted for age and gender.

well as analysis of study attrition is extensively detailed elsewhere(Fleming, 2009; Ritchie et al., in review). Eligible children wereassigned to one of two sites geographically and a random process wasthen used to designate the two sites as either treatment or control.

4.1.1. Cohort 1Overall, 166 children were assigned to groups (87 and 79 to

intervention and control conditions). Study completers totaled 109(54 and 55 to intervention and control conditions). Of completers,self-report behavioral assessment data were available for 40 (22 girls,19 boys, ages 10–12) and 41 (21 girls, 20 boys, ages 10–12) children,respectively. Of these, 33 treatment and 38 controls had data for allparent/caregiver-reported BASC scores. Retention in the control andtreatment groups was 65% and 70%, respectively, after one year. Thislevel of retention is remarkably high for a study of this intensity andduration (Yin et al., 2005). While males were more likely to attriteoverall, there was neither evidence of differential attrition acrosstreatment and control conditions nor was there evidence ofsystematic response bias between BASC-2 completers and non-completers for child or parent reports. Previous research related tothe aims of the original study–that is, assessing effects on childanthropometric and gluco-regulatory characteristics–have been pre-sented elsewhere and indicate that that the treatment reduced insulinresistance and risk for type 2 diabetes in overweight African Americanboys and stabilized it in girls (Raman et al., 2008).

4.1.2. Cohort 2A total of 69 children were recruited into Cohort 2, for which a

complete set of self-report behavioral assessment data were availableat baseline (i.e., prior to participating in either the control ortreatment groups) for 53 children (28 girls, 24 boys, ages 9–10 years old) and a complete set of parent/caregiver-BASC-2 datawere available for 68 children (38 girls, 30 boys, ages 9–10 years old).Cohort 2 baseline scores are used to roughly approximate the initialbehavioral profiles of this sample of children.

The current study, in summary, compares the behavioral profiles,generated from the BASC-2, between those children who wereenrolled in the original treatment program and those enrolled in aless intensive control program for at least 1 year (referred tothroughout as Cohort 1). For purposes of reference, we also describean estimate of baseline (prior to treatment) behavioral characteristicsfrom a subsequent, cohort (referred to throughout as Cohort 2), aswell as a recent comparable study of overweight children, includingwhite and African American children (Zeller et al., 2004).

Based on prior research documenting psycho-social distressamong obese/overweight children, we expected to observe elevatedpsycho-social distress in the baseline study cohort (Cohort 2). Giventhe social-cognitive components of the original intervention, as wellas content added during the intervention described above, weexpected to find differences favoring children in the treatmentcondition across global composites of behavioral problems andadaptive composites from both parent and child reports.

4.2. Treatment condition

Bandura's Social Cognitive Theory (Bandura, 1997) provided theconceptual framework for the original program. Thus, the focus wason improving self-efficacy in relation to health-promoting lifestylehabits through the promotion of healthy eating behaviors, increasedphysical activity and the development of psycho-social skills throughactivities that are enjoyable for children. In addition, the curriculumwas developed to be culturally responsive to the needs of inner-cityAfrican American children and their families by encouraging healthierfood choices with consideration of the financial, physical and culturallimitations and preferences of the children and their families. Inaddition, it used the “personal best” approach to increase physical

836 S. Stone et al. / Children and Youth Services Review 32 (2010) 833–839

activity even in children who previously were not physically active;and creating an environment that fostered respect for self and others.All components were designed to be implemented in minimallyequipped, inner-city community facilities. To mitigate stigma pro-cesses, the overall program used a ‘health at every size’ (versus aweight management) approach. The aim was for participants toimprove nutrition and physical activity relative to their current state.The program incorporated elements from various widely used, relatedcurricula as described elsewhere (Ritchie et al., in review).

Child participants were invited to attend a two-week long summerday camp at the inception of the study after baseline anthropometricand gluco-regulatory data were collected. This was followed by foursessions each month for the next 11 months. The summer day campoffered a unique set of nutrition, physical, and psycho-social activitieson a daily basis. Programming provided an intensive opportunity forteam building, curriculum delivery and family engagement. Duringthe 11-month follow-up period, participants were offered a 2-hourlong intervention-session each week, wherein participants continuedto engage in activities and instruction on nutrition, physical activityand self-competence building. Each month, approximately 4h werededicated to physical activity modeling, and 1h each for hands-onnutrition education and skills building, and modeling. Parents andcaregivers were invited and encouraged to participate in monthlynutrition education and discussion sessions. Particularly in referenceto the current secondary analysis, the psycho-social portion of thechildren's program focused on the development of self-awareness,goal setting, and the ways in which thoughts and feelings combine toinfluence behavior. In addition, positive interactions with others weremodeled (e.g., how to handle teasing or gossip) as well as strategies toresolve conflict.

4.3. Control condition

Children in the control group were invited to attend a one-weeksummer day camp offered by the local YMCA to children 8–14 years ofage. The content and theme of these camps varied by week and,although there were opportunities to be active, no specific program-ming was in place to encourage or support adoption of a healthierlifestyle. In addition, controls, on a monthly basis, received informa-tion in the mail including healthy recipes and information about freeand low-cost opportunities for participation in community sports andhealth-promotion. Their families were invited three times yearly toattend an evening at their local YMCA branch where staff deliverednutrition education to the adult family members, and child partici-pants were encouraged to prepare healthy snacks and engage inphysically active games.

4.4. Behavioral assessment

Behavioral measures were obtained from children and caregiversafter one year of intervention using the BASC-2 (Reynolds &Kamphaus, 2002). The BASC-2 is a widely used, broad-bandinstrument of child functioning that utilizes multiple raters includingchildren (aged 4–18), caregivers, and teachers (for detailed instru-ment reviews, see Flanagan, 1995; Gladman & Lancaster, 2003). It wasdeveloped for educational and mental health assessment and allowsfor ratings of both clinically significant and adaptive behaviors on afour-point scale, ranging from never to always, in addition to true/false responses.

Prior research provides assessments of both convergent andcriterion validity with the Child Behavioral Checklist (CBCL; Achenbach,1991) and with DSM-based disruptive behavioral disorders (AmericanPsychiatric Association, 1994), respectively (Doyle, Ostrander, Skare,Crosby, &August, 1997). Overall, it is considered comparable to theCBCLand can be completed within 10–20min (Gladman & Lancaster, 2003).The BASC has been normed on both general and clinical samples and is

valid and reliable (in the current sample, child and parent internalconsistencies range from 0.71 to 0.94 and from 0.65 to 0.95,respectively). The current study reports on the core clinical and adaptiverating scales available from the instrument including the 14 primaryscales, 4 composites (externalizing problems, internalizing problems,behavior symptoms index, and adaptive skills), and 7 content scales.From child reports we examine the 14 primary scales and 5 composites(inattention/hyperactivity, internalizing problems, emotional symp-toms index, school problems, and personal adjustment).

4.5. Analytic strategy

Analyses took place in two steps. First, we examined differences(adjusted by age, socio-economic status, and sex) between Cohort 1children participating in the treatment versus control conditionsacross all child- and caregiver-reported primary scales, compositesand content scales. We then provided an estimate of the clinicalsignificance of BASC-2 scores compared to normed samples bycapitalizing on results generated from the addition of pre-interven-tion BASC-2 scores using a subsequent study cohort, Cohort 2, as wellas a recent, descriptive study of the psychological adjustment of 66obese children (55% white; 45% African American) of similar age alsousing the BASC-2 (Zeller et al., 2004).

5. Findings

Table 2 presents adjusted means T-scores for children inintervention and control conditions, from the perspective of parents.Parent-reported post-intervention scores favored the interventioncondition on three of the four key composites including behavioralsymptoms index, internalizing problems and adaptive skills, althougha conventional level of statistical significance was only reached foradaptive skills. There were no between group differences on theexternalizing composite. Analyses of decomposed composites—whichidentify specific subcomponents contributing to group differences,revealed significant differences between groups for post-interventionanxiety scores, with marginal significances for atypicality anddepression. Also, there were significant differences between groupsfor the adaptive indices of adaptability, functional communication,and leadership. Of the 7 content scales, differences between groupswere statistically significant for three scales (executive functioning,negative emotionality and resiliency) and marginally significant forone scale (emotional self control).

Given that these group differences are generated from post-treatment BASC-2 assessments, we estimated the clinical significanceof baseline BASC-2 scores from Cohort 2, assuming that the two studycohorts would be comparable on pre-intervention BASC-2 scores. Thisanalysis suggests at risk or clinically significant impairment for two ofthe four composites, seven of the fourteen primary scales, and 4 of the7 content scales. Based on these results, our community sampleappears at greater psycho-social risk than the normed sample(Reynolds & Kamphaus, 2002) and also appears greater than wasreported by others for obese children presenting for weightmanagement, although this subsequent sample includes both whiteand African American children (Zeller et al., 2004).

Table 3 presents adjustedmeans T-scores for children in treatmentand control conditions, from the perspective of the childrenthemselves. We found no composite level, group differences betweenchildren in the intervention and control conditions; and differencesbetween groups were observed for only 2 of the 14 primary scales(atypicality and self-esteem). Of note, the pre-intervention compar-ison cohort showed at risk/clinically significant scores across four ofthe five composites, and five of the fourteen primary scales, puttingthem at greater psycho-social risk than the normed sample andgreater than children presenting for weightmanagement (Zeller et al.,2004).

Table 2Parent report — adjusted mean T-scores on BASC-2 scales for intervention and control groups, with comparison cohorts.

Cohort 1 Comparison samples: % at risk/clinically significantb

Interventiona Controla

Adj. mean(n=33)

Adj. mean(n=38)

Baseline Cohort 2(n=68)

Zeller et al. (2004)(n=62)

Behavioral symptoms index 48.59† 52.44 26* n/aExternalizing problems composite 49.43 52.36 24 21Internalizing problems composite 48.31† 53.31 31** 52

Aggression 48.22 50.97 26* 27Anxiety 47.13* 53.35 29** 29Attention problems 51.94 55.29 32*** 39*Atypicality 49.42† 52.77 28* 27Conduct problems 50.96 53.09 24 29Depression 47.71† 52.06 35*** 47*Hyperactivity 49.28 52.60 18 23Somatization 51.11 52.63 15 48*Withdrawal 46.59 47.95 25† 39*

Adaptive skills composite 52.40* 47.71 18 45Activities of daily living 47.45 45.77 35*** n/aAdaptability 52.03* 47.10 29** 40*Functional communication 51.82* 46.81 18 n/aLeadership 56.43** 50.78 15 32Social skills 52.49 49.69 16 37*

Content scalesAnger control 49.53 51.71 15 n/aBullying 51.72 52.05 25† n/aDevelopmental social disorders 48.39 51.29 28* n/aEmotional self control 48.17† 53.44 9† n/aExecutive functioning 47.35* 52.35 19 n/aNegative emotionality 46.30** 53.34 31** n/aResiliency 51.88* 46.97 25† n/a

Note: †=p≤0.10, *=p≤0.05, **=p≤0.01, ***=p≤0.001 (two-tailed tests of significance).a Adjusted for child sex, age and socio-economic status.b Based on differences between sample proportions and BASC-2 norms; Zeller et al. (2004) cohort 55% white; 45% African American.

837S. Stone et al. / Children and Youth Services Review 32 (2010) 833–839

6. Discussion

The current study was motivated by the paucity of interventionresearch focused on the psycho-social attributes of inner-city overweightand obese children, despite clear evidence of psychological distress

Table 3Child report — adjusted mean T-scores on BASC-2 scales for intervention and control group

Cohort 1

Interventiona C

Adj. mean(n=40)

A(

Emotional symptoms index 48.11 5Inattention/hyperactivity composite 55.04 5Internalizing problems composite 48.82 5School problems composite 54.82 5

Anxiety 49.40† 5Attention problems 55.09 5Attitude to school 51.85 4Attitude to teachers 56.72 5Atypicality 47.06** 5Depression 47.85 4Hyperactivity 54.39 5Locus of control 53.64 5Social stress 48.33 5Sense of inadequacy 47.66 4

Personal adjustment composite 49.36 4Relations with parents 44.88 4Interpersonal relations 51.29 5Self-esteem 51.38* 4Self-reliance 50.69 4

Note: †=p≤0.10, *=p≤0.05, **=p≤0.01, ***=p≤0.001 (based on two-tailed tests of signa Adjusted for child sex, age and socio-economic status.b Based on differences between sample proportions and BASC-norms.

among affected children. It represents, to our knowledge, a secondaryanalysis of one of the few intervention studies that simultaneouslyconsidered outcome measures across biologic (e.g., anthropometric,gluco-regulatory) and psycho-social domains. Our expectations werepartially supported.According toparent reports, scoresonkey clinical and

s, with comparison cohorts.

Comparison samples: % at risk/ clinically significantb

ontrola

dj. meann=41)

Baseline Cohort 2(n=50)

Zeller et al. (2004)(n=62)

1.35 28** 14.55.04 50*** 14.52.13 26† 14.54.37 34** 163.31 26† 235.74 46*** n/a9.38 16 118.40 36*** 163.74 20 129.26 22 153.64 48*** n/a4.34 42*** 80.52 20 239.36 12 187.09 30* 185.26 22 150.07 28* 246.36 26† 269.60 24 11

ificance).

838 S. Stone et al. / Children and Youth Services Review 32 (2010) 833–839

adaptive composites favored children in the intervention condition.However, child reports indicated no post-treatment differences oncomposites of interest. Overall, we urge a cautiously optimisticinterpretation of these findings. On the one hand, it is imperative toconsider the probability of Type 1 error (i.e. that thesefindings couldhavebeen generated by chance, given multiple comparisons). On the otherhand, childhood overweight and obesity is best conceptualized within acontextual framework, involving biologic, family, and community factors(see Davison & Birch, 2001), leading to the conclusion that proximalinterventions–suchas theoneutilized in theoriginal study–are inherentlyunderpowered to detect intervention effects (Thomas, 2006). In thisrespect, our analytic approach (e.g.., reliance on two-tailed tests ofsignificance) would be considered conservative. These results should beinterpreted as preliminary and the effects of treatment can only be fullydetermined by performing a subsequent randomized controlled studywith both pre- and post-testing andwithin the context of an interventionthat deliberately targets psychological distress.

That the intervention appeared to more strongly relate tointernalizing symptoms and adaptive functioning is not surprising.As noted, relevant components of the original intervention largelyfocused on self-esteem and self-perception-related processes. Theintervention did not focus on parent management of child behavioraldifficulties, a key evidence-based component of the effectivemanagement of inattentive, disruptive, and/or aggressive behaviors(Kazdin, 2005). The results, however, are notable in that a fairly non-specific, social cognitively-oriented strategy can show improvementsacross anthropometric, gluco-regulatory (see Raman et al., 2008), andpsycho-social domains among overweight and obese children. At thevery minimum, our results suggest the promise of developinginterventions that have the potential of crossing biologic andpsycho-social domains, especially in light of the common conceptualunderpinnings in both childhood obesity prevention/intervention andmental health literatures. It is also critical to understand what specificintervention components relate to reduced psychological distressamong affected children. The current study is unable to determinewhether or what combination of parent involvement and education,nutrition education, physical activity or psycho-socially-orientedcontent accounted for intervention effects. The discrepancy infindings between parent and child reports needs further investigation,especially given that children are likely a more reliable reporter ofinternalizing symptoms (Weisz, et al., 2005). However, other studiesof obese children show a similar pattern of effects (Zeller et al., 2004).

Finally, our comparative results suggest that community samples ofobese and overweight children may be in more psychological distressthan originally estimated, especially in the realm of externalizingsymptoms (Braet et al., 1997; Zeller et al., 2004). Because the currentstudy purposefully selected inner-city, African American children,however, it is unclearwhether these indicators of psychological distressreflect a sample selection bias, where parents of children withpsychological distress were more likely to agree to study participation,whether they relate to the socio-demographic background of targetchildren (e.g., African American, low income, living in a challengingneighborhood environments), or an interactive combination of thesefactors. Our results do suggest that subsequent programs targetingchildren of similar backgrounds should consider the potential inter-vention implications related to such behaviors. Indeed, there has beenlittle formal considerationof theways inwhichchild-level psychologicaldistress may impact the delivery of health-related interventions amongoverweight and obese children.

In light of the critical study level limitations (e.g., sample selection atcommunity and site levels; overall attrition levels and non-response,post-hoc analyses of behaviorally-related effects), we would argue thatthey should be considered in context of the overall quality of the currentintervention literature. At minimum, our results suggest a need forfurther multi-disciplinary efforts that move beyond solely medical andnutritional to also include psycho-social intervention.

Acknowledgments

The authors gratefully acknowledge the wonderful collaborationof the YMCA of the East Bay in Oakland, CA. Essential funding wasprovided by USDA CSREES grants 2004-35214-14254 and 2005-35215-15046, the Agriculture Experiment Station and the YMCA. Theauthors are indebted to the participating children and their families,to UC Berkeley student assistants, to all members of the Taking ActionTogetherAdvisory Board, and to Joanne Ikeda, Mark Fitch, Mark Hudes,Barbara Green, Rita Mitchell, Matt Johnson, and Molly Fyfe.

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