Behavioral strategies for better adherence

Interviews with families help identify problem areas

Families were not putting into practice strategies for weight loss given by clinicians at the University of Wisconsin Hospital and Clinics in Madison to help overweight teens.

Therefore, Susan K. Riesch, PhD, RN, FAAN, a professor at the University of Wisconsin-Madison School of Nursing, was asked if her team of researchers would develop some behavioral strategies to help parents follow through on clinic recommendations.

According to Riesch, the staff at the pediatric primary care clinic provides all kinds of ideas, such as eating together as a family or not allowing second helpings at meals, but parents find it difficult to follow through.

The team is focusing on a parenting model known as balanced parenting, or authoritative parenting. This model is a child-centered approach that encourages children to be independent but still places limits on their actions. A child's input is valued.

"With this style, parents balance their warmth and acceptance with their strictness and control," explains Riesch.

There are three parenting styles, says Riesch. In addition to the authoritative parent, there is the authoritarian parent who is not very warm and is very strict and controlling. Also, there is the permissive parent who is not very good at keeping rules, which provide structure by setting clear limits and consequences for infractions.

Although the behavioral strategies are a work in progress, Riesch and her team have come up with a three-pronged approach.

First, the team developed scenarios to show how situations other than weight loss are handled by an authoritarian parent, a permissive parent, and a parent with an authoritative style, so parents at the clinic will better understand the various parenting styles. For example, scenarios show how a parent reacts to a failing grade on a test or missing a curfew according to the different parenting styles.

"We want to provide scenarios so that parents can be aware or observe approaches," says Riesch. Hearing the different ways that parents can handle situations might help them get to a point where they could apply better strategies to weight loss problems, she explains.

To help parents develop the confidence to follow through, to not only demonstrate warmth and acceptance toward their child, but also an expectation of mature behavior, a booklet was developed to provide inspiration through short daily readings.

Finally, curriculum titled "Parenting Through Change" was developed to give parents the skills to be demanding, to impose consequences, and to enforce rules that are developed in collaboration with the youth.

"We hope to provide the empirically supported 'Parenting Through Change' curriculum electronically with copious support to parents as part of their treatment protocol in primary care. Of course, this will require considerable commitment and follow-through from parents, but it should provide them the skills to structure the family for better psychosocial outcomes," says Riesch.

She adds that the steps given in this approach are referred to as the behavioral prescription. Families are given a prescribed diet plan and exercise regime, and they will also be prescribed steps on behavioral changes for improved parenting.

The first step will ask parents to identify things that are going on in their home they really like by having them focus on the positive.

The second step will be to identify the number-one behavior they would like to change. This might be something as simple as getting the children to hang up their coats when they come home from school.

"Parents will observe the behavior for one week, tracking how many times the children hang up their coats when they come home from school without giving any direction. Then they will move to making the request and giving rewards," says Riesch.

Parents will have worksheets to complete and show to clinic staff as they work through the curriculum, and they will need to either check in at the clinic or complete the homework online. Riesch said clinic staff will be available weekly to provide guidance. The curriculum is expected to help them make necessary changes in their parenting style and improve their communication.

Plan developed with family input

To gather information to put a plan in place, Riesch and her team first surveyed parents and their overweight teens to get an idea of their parenting style. The survey was followed up with focus groups.

"In the survey, most parents perceived themselves as firm or strict, whereas, moderate is the desired level of control," explains Riesch. "The focus groups gave us an entirely different view, showing parents were struggling to follow through with the recommendations of the primary care clinics."

Results from focus-group research with children and their parents in the study suggest four key areas on which Riesch believes families should focus. They are mixed messages, food and exercise as battlegrounds, problem-solving, and social support.

In the parental mixed messages category, behavior often contradicted the instruction from the clinic. For example, youth and parents knew the clinic recommended they eat together as a family as often as possible, yet the parents would confess the dining room table was always piled high with things, making it difficult to use for meals.

Battles over food choices might occur when a parent put a healthy breakfast on the table, only to be told the teen wasn't hungry or didn't have time to eat. Then on the way to school, the teen would ask the parent to stop for fast food, "just this once."

"The teens knew they could coerce the parent into breaking down whatever new rule had been made," said Riesch.

In the area of problem-solving, Riesch and her team found some parents were beginning to figure out how to work with their overweight child to eat better and be more active. For example, one father walked daily with his son, taking notes about the animals or plants they saw. Each day they added 20 seconds to the walk and were up to 30 minutes.

Also, youth appreciated it when parents replaced unhealthy snacks with healthy ones, said Riesch.

Social support was something children needed for better weight-loss efforts. Also, parents often experienced frustrations trying to implement the health care provider's recommendations, and they appreciated discussing ideas with other parents. Riesch says the research team is not sure how to address this, but support groups of some sort might be beneficial.

"There are a number of key factors that can help teens make lifestyle changes, both at home and when they're at school or out in the community. While there are no simple fixes, these four focus areas are a good starting place," says Riesch.


For additional information on the program being set in place to assist clinicians working with overweight teens, contact:

• Susan K. Riesch, PhD, RN, FAAN, Professor, University of Wisconsin-Madison School of Nursing, 600 Highland Ave CSC H6/238, Madison, WI 53792. Telephone: (608) 263-5169. E-mail: