Parent Involvement in Adolescent Treatment: A Systematic Review Melanie K. Bean, PhD,a Laura J. Caccavale, PhD,a Elizabeth L. Adams, PhD,a C. Blair Burnette, MS,b Jessica Gokee LaRose, PhD,c Hollie A. Raynor, PhD, RD, LDN,d Edmond P. Wickham, III,, MD, MPH,e,a Suzanne E. Mazzeo, PhDb,a

CONTEXT: Family-based lifestyle interventions are recommended for adolescent obesity abstract treatment, yet the optimal role of parents in treatment is unclear. OBJECTIVE: To examine systematically the evidence from prospective randomized controlled and/or clinical trials (RCTs) to identify how parents have been involved in adolescent obesity treatment and to identify the optimal type of parental involvement to improve adolescent weight outcomes. DATA SOURCES: Data sources included PubMed, PsychINFO, and Medline (inception to July 2019). STUDY SELECTION: RCTs evaluating adolescent (12–18 years of age) obesity treatment interventions that included parents were reviewed. Studies had to include a weight-related primary outcome (BMI and BMI z score). DATA EXTRACTION: Eligible studies were identified and reviewed, following the Preferred Reporting for Systematic Review and Meta-Analyses guidelines. Study quality and risk of bias were evaluated by using the Cochrane Collaboration risk of bias tool. RESULTS: This search identified 32 studies, of which 23 were unique RCTs. Only 5 trials experimentally manipulated the role of parents. There was diversity in the treatment target (parent, adolescent, or both) and format (group sessions, separate sessions, or mixed) of the behavioral interventions. Many studies lacked detail and/or assessments of parent-related behavioral strategies. In ∼40% of unique trials, no parent-related outcomes were reported, whereas parent weight was reported in 26% and associations between parent and adolescent weight change were examined in 17%. LIMITATIONS: Only RCTs published in English in peer-reviewed journals were eligible for inclusion. CONCLUSIONS: Further research, with detailed reporting, is needed to inform clinical guidelines related to optimizing the role of parents in adolescent obesity treatment.

aDepartment of Pediatrics, Children’s Hospital of Richmond at Virginia Commonwealth University, Richmond, Virginia; bDepartment of Psychology, College of Humanities and Sciences and cDepartments of Health Behavior and Policy and eInternal Medicine, School of Medicine, Virginia Commonwealth University, Richmond, Virginia; and dDepartment of Nutrition, The University of Tennessee, Knoxville, Knoxville, Tennessee

Dr Bean conceptualized and designed the study (including determination of inclusion and exclusion criteria), conducted a critical review of literature, performed quality assessments, drafted the initial manuscript, and critically reviewed and revised the manuscript; Dr Adams, Ms Burnette, and Dr Caccavale conducted the systematic review of the literature and determined which studies met inclusion and exclusion criteria, extracted the data and performed quality assessments, drafted the initial manuscript, and critically reviewed and revised the manuscript; Drs Mazzeo, LaRose, Raynor, and Wickham conceptualized and designed the study and critically reviewed and revised the manuscript; and all authors approved the final manuscript as submitted and agree to be accountable for all aspects of the work.

To cite: Bean MK, Caccavale LJ, Adams EL, et al. Parent Involvement in Adolescent Obesity Treatment: A Systematic Review. Pediatrics. 2020;146(3):e20193315

Downloaded from www.aappublications.org/news by guest on September 26, 2021 PEDIATRICS Volume 146, number 3, September 2020:e20193315 REVIEW ARTICLE More than one-third of children in the improving adolescent weight home environment strongly United States have or outcomes.11 Evidence-based guidance influences children’s lifestyle obesity; rates are even greater among addressing the optimal role of parents choices.30,31 Yet a closer examination adolescents and racial and ethnic in adolescent obesity treatment is of the literature reveals that few minorities.1 Youth with obesity face needed to inform empirical studies have investigated the role of a significant lifelong burden of investigations, enhance treatment parents in adolescent cardiometabolic disease, including effectiveness, and provide clear and treatment.22,32,33 In addition, there is – type 2 diabetes2 5; thus, the need for consistent guidance to providers. no consensus regarding how to effective adolescent obesity treatment optimize parental involvement across Obesity during adolescence is likely – developmental stages.11,13,18,19,34 36 is urgent. Family-based lifestyle to persist into adulthood.14 This In an integrative review of parent interventions are recommended for developmental stage is a unique, yet participation in obesity interventions pediatric obesity treatment, and vital, opportunity for family-based with African American adolescent clinical guidelines consistently treatment. In general, family-based girls, the authors noted the lack of emphasize the importance of adolescent obesity treatment yields data regarding the ideal type of including parents in these modest improvements in BMI and 6–10 – parental involvement; they further interventions. Indeed, metabolic risk factors.15 17 Parental highlighted the need for evidence a systematic review of evidence- involvement in treatment is regarding which parent variables are based clinical practice guidelines, associated with even better health associated with adolescent BMI position, and consensus statements outcomes,18,19 with results of a meta- reduction.32 Although clinical on the management of pediatric analysis suggesting that it accounts guidelines consistently emphasize the obesity found that all of the included for ∼20% of the variance in child importance of including parents in statements recommended that weight.18 Most studies targeting pediatric behavioral weight loss parents be involved in an adolescent obesity in youth were conducted with interventions, the optimal way in lifestyle intervention.11 More recently, school-aged children; less is known which to operationalize this the American Psychological about adolescent populations. involvement is unknown. As such, our Association published evidence-based Adolescence can present substantial goal for this article is to clinical practice guidelines for the challenges to family-based care systematically review the research on behavioral treatment of obesity in because it is marked by behavioral lifestyle interventions (ie, children and adolescents and a developmentally normative period those that address diet, physical recommended family-based of opposition to authority, role activity, and/or behavior change to multicomponent behavioral transformations, and increasing achieve weight loss) for adolescent interventions for children and personal responsibility.20,21 obesity that involve parents to adolescents with overweight or Adolescents experience an increased identify (1) how parents are included fi desire for independence and obesity. Speci cally, the policy states, in treatment and (2) the optimal role “ autonomy, yet they still rely on the intervention is not solely of parents within treatment to … parents for many needs.21 Given provided to the adolescent; enhance adolescent weight loss (eg, … these challenges, it is not surprising rather involves the parents and BMI), specifically, which elements of that research investigating specific potentially other family members as parental involvement are positively …”12 clinical paradigms for parent active participants. Similarly, the associated with adolescent involvement in adolescent obesity American Academy of Pediatrics weight loss. recommends involving parents in treatment is inconsistent, with mixed fi obesity treatment through strategies ndings regarding the ideal level of fi such as parental monitoring, limit parental involvement and the speci c METHODS setting, reducing barriers, managing parenting strategies that can optimize 11,22 The conduct and reporting of this family conflict, and modifying the treatment. review adhered to the Preferred 13 home environment. However, A focus on parents is vital for Reporting Items for Systematic 37 despite these clear recommendations childhood obesity treatment for Review and Meta-Analyses. This to involve parents in their numerous reasons. For example, review was deemed exempt from adolescents’ obesity treatment, there parental obesity is associated with institutional review board review. are limited data to support which child overweight,8,23 parents are specific parental involvement powerful role models of eating and Study Selection strategies should be used, and there exercise behaviors,24,25 parent Randomized controlled and/or is even less information about which feeding behaviors influence children’s clinical trials (RCTs) (either active strategies are most effective in eating habits and weight,26–29 and the comparator or control group) used to

Downloaded from www.aappublications.org/news by guest on September 26, 2021 2 BEAN et al evaluate a behavioral weight loss independently by 2 authors (L.J.C. and high risk, or unclear risk by using intervention (ie, addressed diet, C.B.B.) in April 2018. An updated guidelines from the Cochrane tool. physical activity, and/or behavior search was conducted in July 2019 by change) among adolescents aged 12 using the same search terms and to 18 years without major intellectual databases above to identify any RESULTS or developmental disabilities were studies published in the previous In the initial PubMed search, we considered. Trials had to be year that met inclusion criteria. retrieved 1070 articles. Search results conducted in the United States (given from all databases were filtered to that the obesogenic environment, Screening and Data Extraction include only RCTs and were parenting roles, and family structure consolidated to remove duplicates, All retrieved citations were screened vary geographically) and had to resulting in 356 unique articles by 2 independent authors following include some degree of parental (Fig 1). An additional 9 articles were predetermined inclusion criteria involvement with a weight-related retrieved from bibliographies of (L.J.C. and C.B.B.). Duplicates were primary adolescent outcome (eg, BMI, relevant reviews. Ultimately, 32 removed; multiple articles published BMI z score). Published articles had articles met criteria to be included in from the same trial were included if to be peer reviewed, had to be this systematic review (n =30from the outcome measure, follow-up time written in English, and had to have n frame, or parent variables differed. the original search; =2fromthe full text available. Studies were updated search conducted in July Titles and abstracts of all articles excluded if the trial did not include 2019). Of these 32 articles, there were reviewed, followed by full-text a control or comparison group, was were 23 unique trials, with 6 trials articles if inclusion could not be focused on obesity and/or weight having .1 published article included determined from the title and gain prevention or weight within the in this review. abstract. In the case of disagreements context of a medical condition (eg, at each stage of the selection process, ), or tested a drug and/or There was strong consistency in bias consensus was reached through surgical intervention. ratings between raters (99.1%); discussion with a third author 100% of discrepancies were resolved Information Sources and Search (M.K.B.). A data extraction template by consensus. Of the 23 unique trials, Strategy was then developed to meet the aims 56.5% were rated as low risk, 34.8% of this review. This form was pilot The search strategy was developed in were rated as unclear risk, and 8.7% tested on a sample of studies and consultation with an information were rated as high risk of bias revised before use. Two authors specialist (Mrs Nita Bryant, Virginia (Table 1). Of the studies with an (L.J.C. and C.B.B.) independently Commonwealth University). A unclear risk, most did not report extracted data from each included comprehensive literature search was when randomization occurred, how article, including bibliographic conducted through the electronic procedures were applied, and/or if information, population databases PubMed, Medline, and participants were masked (although (demographics, sample size, and PsychINFO. The following search it is typically not feasible to keep baseline characteristics), parent terms were included to retrieve participants masked in behavioral involvement, study design (duration, studies based on participants and treatment). contact, and format), adolescent outcomes, with the Boolean phrase intervention approach, parent “AND” used between groups and “OR” Overall Description of Included intervention approach, adolescent used within groups, to maximize the Studies weight outcomes, and parent search’s sensitivity: (adolescent* OR Most trials contained ,100 outcomes (if reported). teen*) AND (obes* OR overweight OR participants (n =31–209). In all but 1 weight loss OR weight management trial,64 the majority of adolescent Quality Assessment OR weight control) AND (parent* OR participants were female caregiv* OR family) AND The Cochrane Collaboration risk of (∼60%–80%); 5 trials only enrolled (intervention OR trial OR treatment bias tool was used to assess the risk girls.36,45,55,63,68 In 11 trials,* the OR behavior therapy OR randomized of bias among the RCTs in this majority of participants were white controlled trial). Searches were review.38,39 Two authors (L.J.C. and (55%–100%); in 8 limited to “English,”“human,” and C.B.B.) independently applied these trials,36,40,46,57,58,63,66,68 the majority “RCT” when appropriate. Reference criteria. Discrepancies were of participants were African American lists of systematic reviews, meta- discussed, and if consensus could not (in 7 trials, only African Americans analyses, and related articles were be reached, a third author was were enrolled). hand searched for potential citations. consulted (M.K.B.). Each study was Searches were conducted given an overall rating of low risk, * Refs 43,45,47–49,51,53,55,56,64,67.

Downloaded from www.aappublications.org/news by guest on September 26, 2021 PEDIATRICS Volume 146, number 3, September 2020 3 BMI,36,47,51,57,63,65,69 and BMI z score.45,47,48,55,62,64,66,67 A few studies that reported BMI outcomes also reported kilograms of weight lost36,69 and/or body composition, body percentage, or other measures of adiposity.57,65,68,69 Studies that did not report BMI outcomes tended to report change in weight (kilograms or percentage) instead,43,49,56 whereas one trial reported percentage change in overweight as the primary outcome.58 In 11 trials, intervention group differences in weight outcomes were found,# and in 1 trial, a trend for group differences on BMI reduction was found.53 In 10 trials, no intervention group differences in weight outcomes were found,** but of these, 6 trials resulted in weight loss for all study groups.36,42,47,51,58,67

Description of Parent Involvement Intervention Format In some trials (n = 8), the FIGURE 1 intervention was delivered to parents Preferred Reporting Items for Systematic Reviews and Meta-Analyses flow diagram. and adolescents separately,40,44,45,48,51,53,56,68 and in { n Most interventions had a 4- to 6- solving or goal setting to promote other trials ( = 6), parents and † adolescents were together in joint month treatment duration. The behavior change. Other behavioral 46,47,55,57,58,66 remaining had a treatment duration strategies included relapse group sessions. In fewer n of ,4 months56,66,67 or prevention and/or trials ( = 4), 1 experimental 1 year.40,42,47,62,65 Twelve trials had maintenance,49,51,53,65,67 stress condition was tested with joint group no follow-up to assess weight loss management,40,42,49,53,66 contingency sessions and another experimental maintenance.‡ Of the trials that did management,40,42,65 cognitive condition was tested with separate sessions for parents and assess maintenance, follow-up restructuring or managing beliefs 36,42,43,64 periods varied at 3,64 6,36,45,48,49,63 about weight loss,40,42,43,53,57,65 adolescents. Five trials 8,51 9,44 and 1243,56,67 months in depression management,45 promoting included at least 1 experimental duration. social support,40,42,43,45,55,62,64,67 condition in which parents and managing cravings,53,57,58 use of adolescents attended both separate All of the interventions included incentives and/or and joint group sessions; for example, a lifestyle modification program rewards,36,44,46,58,64,67 sleep parents and adolescents attended targeting diet and exercise behaviors education,66 and addressing separate group sessions each week, to promote healthy weight loss. with joint dyad meetings disordered eating or promoting 49,62,63,65,67 Studies varied in their description of a healthy body image.45,53 biweekly. the adolescent intervention, but most described using self-monitoring,x BMI was the most common variable Behavioral Techniques Involving Parents ‖ stimulus control, and problem- used to measure adolescent All studies listed the behavioral treatment outcomes, yet it was components or strategies taught to † Refs 36,43–46,48,49,51–53,55,57,58,63,64,68. operationalized in different ways parents, but few described them in ‡ Refs 40,42,46,47,53,55,57,58,62,65,66,68. across studies, including change in detail. These parent behavioral 40,42 x Refs 36,40,42,43,45,46,48,49,51,53,55,58,62,64,68. BMI percentage, ‖ Refs 40,42,43,46,49,51,53,58,64,65,67. # Refs 40,43–45,48,49,56,57,64,65,68. { Refs 40,42,46,48,49,51,53,55,62–68. ** Refs 36,42,47,51,55,58,62,63,66,67.

Downloaded from www.aappublications.org/news by guest on September 26, 2021 4 BEAN et al EITISVlm 4,nme ,Spebr2020 September 3, number 146, Volume PEDIATRICS TABLE 1 Characteristics of Studies Included in a Systematic Review on the Role of Parents in Adolescent Obesity Treatment Study (Year) n; Age; Sex; Race Adolescent Intervention Parent Involvement Methods Treatment Primary Adolescent wt Parent Outcomes or Implications Related to Risk of and/or Ethnicitya Length Outcomes Relation of Parents to Role of Parents Biasb Adolescent Outcomes Berkowitz n = 113; 15 6 1.3 y; Adolescents randomly All groups: parents in 12 mo At 4 mo, adolescents in LMP None reported The role of parents in Low et al40 female sex: 81%; assigned to (1) LMP and separate groups from and MR group had treatment outcomes is (2011) African American: LCD for 12 mo; (2) LMP and adolescents (parent greater %BMI reduction unclear because of 62%, white: 26%, MR for 4 mo, LCD for 8 mo; groups not described) (6.3% 6 0.6%) than design and lack of other or unknown: (3) LMP and MR for 12 mo adolescents in LMP and reporting on parent 12% LCD group; from 5 to 12 variables.

Downloaded from mo, no group differences in D%BMI Xanthopoulos See Berkowitz et al40 See Berkowitz et al40 (2011) See Berkowitz et al40 (2011) 12 mo See Berkowitz et al40 (2011) Parents lost 2.0% of initial When both the adolescent Low et al41 (2011) BMI at 4 mo and and parent(s) have (2013)c maintained a 1.3% loss excess wt, it appears at 12 mo; significant especially beneficial for

www.aappublications.org/news association between long-term adolescent wt parent and adolescent loss that parents D%BMI from 0 to 4 mo engage in their own wt and from 0 to 12 mo; loss efforts. when parents lost more than the median at 4 mo, adolescents had greater wt loss at 12 mo compared with adolescents whose

byguest on September26, 2021 parents lost less than the median at 4 mo Berkowitz n = 169; 14.6 6 1.4 y; Adolescents randomly Group: parents in separate 12 mo Adolescents in both groups None reported Both groups included Low et al42 female sex: 77%; assigned to: (1) group LMP, groups from adolescents had significant D%BMI parents and had (2013) African American: (2) self-guided LMP (met (parent groups not reduction from 0 to 12 comparable outcomes; 47%, white: 47% with health coach and described); self-guided: mo (group: 1.3% 6 the role of parents is reviewed self-guided parent and adolescent 0.95%; self-guided: 1.2% unclear because of lessons) grouped together (parent 6 1.0%); no group design and lack of in a supporting role) differences in D%BMI reporting on parent variables. Brownell n = 42; 13.8 6 1.4 y; All adolescents received MCS: mothers told they 16 wk MCS adolescents had No differences in mother Greatest adolescent wt Unclear et al43 female sex: 78%; group LMP, randomly were crucial to success greater Dwt from 0 to 16 Dwt between groups; loss achieved when (1983) white: 100% assigned to (1) MCS and encouraged to wk (8.4 kg) than other Mother Dwt was not mothers and (concurrent groups), (2) communicate and/or groups (5.3 and 3.3 kg); correlated with child adolescents were MCT, (3) CA work together with magnitude of differences Dwt treated separately but adolescents; MCT: increased at 1 y concurrently participants were told being together in groups was optimal; CA: no parent involvement Coates et al44 PP: parents (separate from 20 wk PP adolescents had None reported Parent participation in High (1982) teenagers) taught to greatest decrease in treatment enhanced 5 6 TABLE 1 Continued Study (Year) n; Age; Sex; Race Adolescent Intervention Parent Involvement Methods Treatment Primary Adolescent wt Parent Outcomes or Implications Related to Risk of and/or Ethnicitya Length Outcomes Relation of Parents to Role of Parents Biasb Adolescent Outcomes n = 31; 15.6 (age All adolescents received support adolescent wt percentage above ideal short-term adolescent range:13–17) y; group LMP, randomly loss through modeling, wt (8.4% by end of wt loss but no long-term female sex: 65% assigned to (1) PP, (2) NP role play, and self- intervention and effect monitoring; parents maintained at follow-up); deposited $95 and PP adolescents and NP refunded on the basis of adolescents had

Downloaded from adherence and post comparable decrease in completion; NP: parents percentage above ideal deposited $35, refunded wt at 9-mo follow-up at post intervention. DeBar et al45 n = 208; 14.1 6 1.4 y; Adolescents randomly Intervention: parents 5 mo Change in BMIz across 12 None reported Home environment Low (2012) female sex: 100%; assigned to (1) LMP with attended separate weekly mo was greater for changes, role modeling,

www.aappublications.org/news white: 75% a multicomponent group meetings in mo intervention adolescents and fostering developmentally tailored 1–3 with the same compared with UC adolescent autonomy behavioral intervention, (2) nutrition and PA content adolescents (20.15 vs was effective as part of UC as adolescents; family 20.08 BMIz) a comprehensive meals, role modeling, and treatment. However, adolescent autonomy with limited or no support emphasized; UC: parent data, the role of parents received a guide parents in treatment to help adolescents make outcomes is unclear. healthy changes 46 6

byguest on September26, 2021 Ellis et al n = 49; 14.5 1.6 y; Adolescents randomly MST: parents learned 6 mo Effect of treatment on BMI MST participants had Family participation in Low (2010) female sex: 77%; assigned to (1) MST: healthy dietary practices, not reported; greater improvements in exercise might be African American: intensive, family-centered, importance of regular adolescents receiving family encouragement associated with better 100% community-based meal and exercise times, MST had increased family and decreased family adolescent wt loss treatment delivered in role modeling of healthy support for healthy discouragement outcomes. home, school, or behaviors, and eating and exercise compared with control neighborhood; (2) control: reinforcement of participants. Increased Shapedown manualized adolescent success; family support for group intervention Control: parents and exercise was negatively adolescents together correlated to 7-mo adolescent BMI, percentage overweight, and body fat; however, analyses did not control for baseline BMI. Fleischman n = 40; 14.3 6 1.9 y; All adolescents received LMP, Both groups: parents and 12 mo BMIz decreased in both Parents reported Offering telehealth might Unclear et al47 female sex: 78%; randomly assigned to (1) adolescents were groups by 12 mo (20.11 acceptability of televisits, help increase parent (2016) white: 88%, other PCP visits plus televisits together in dietitian and 6 0.05); no group and many indicated they engagement in or unknown: 13% with obesity specialists psychologist televisits differences in DBMI would not have adolescent treatment.

ENe al et BEAN (PCP 1 specialists) for 6 otherwise sought mo, then PCP visits only for treatment. 6 mo, (2) PCP visits only EITISVlm 4,nme ,Spebr2020 September 3, number 146, Volume PEDIATRICS TABLE 1 Continued Study (Year) n; Age; Sex; Race Adolescent Intervention Parent Involvement Methods Treatment Primary Adolescent wt Parent Outcomes or Implications Related to Risk of and/or Ethnicitya Length Outcomes Relation of Parents to Role of Parents Biasb Adolescent Outcomes for 6 mo then PCP 1 specialist visits for 6mo Janicke et al48 n = 93; .50% $11 y Families randomly assigned FB: parents and children 4 mo PO adolescents had No differences in parent Potential moderating effect High (2008) (age range: 8–14 to (1) FB, (2) PO, (3) WLC attended simultaneous a greater decrease in DBMI between treatment of age suggested that y); female sex: (separate) groups that BMIz at 4 mo relative to conditions at either adolescents (aged 11 y

Downloaded from 61%; white: included (1) review of WLC (mean difference, assessment time point. and older) might benefit 67%–81%, African progress; (2) nutrition, 0.13). There was no No associations between more from a family- American: PA, and behavior difference between WLC parent DBMI and change based intervention. 4%–14%, Asian education and skills and FB. PO and FB had in child wt status at These children might be American: training; (3) children and a greater decrease in either assessment time more developmentally 4%–17%, mixed parents reconvened for BMIz at 10 mo relative to point. ready to employ the

www.aappublications.org/news race: 0%–11.5% goal setting. PO: same WLC (0.12 and 0.14, skills taught and thus content as FB, but only respectively). There was should be included in parents attended no difference in DBMIz treatment. sessions; parents trained between PO and FB at 4 to work with children on or 10 mo. For children goal setting. $11 y, FB had a 50% greater decrease in BMIz than PO. Jelalian et al49 n = 76; 14.5 6 0.9 y; All adolescents received Both groups: parents and 16 wk Adolescents lost wt in both Parents of adolescents in Parental satisfaction Low (2006) female sex: 72%; weekly group CBT LMP, adolescents in separate treatment conditions, the CBT 1 EXER group equivalent for both

byguest on September26, 2021 white: 78%, other randomly assigned to (1) groups plus biweekly with no group did not differ from groups; with limited or or unknown: 22% CBT plus supervised parent-adolescent dyad differences at 16 wk parents of adolescents in no parent data, the role traditional cardiovascular meetings. Parents (25.31 kg for the CBT 1 PEAT group on of parents in treatment PA (CBT 1 EXER), (2) received similar content CBT 1 PEAT and23.20 kg an overall measure of outcomes is unclear CBT 1 PEAT and information on for CBT 1 EXER); treatment satisfaction family-level percentage of implementation of participants maintaining behavior changes 10 lb wt loss at 10 mo greater for CBT 1 PEAT (35%) than for CBT 1 EXER (12%); age by treatment group interaction with older adolescents in CBT 1 PEAT .4 times greater wt loss than older adolescents in CBT 1 EXER Jelalian et al50 n = 76; 14.5 6 0.9 y; See Jelalian et al49 (2006) See Jelalian et al49 (2006) 16 wk Male sex, nonminority race, Higher baseline parent BMI Potential importance of Low (2008)c female sex: 72%; higher attendance, and predicted attrition at 4 attending to parental white: 78%, other early wt loss predicted mo (adolescents of BMI in efforts to retain or unknown: 22% greater wt loss at 16 wk heavier parents were 7 8 TABLE 1 Continued Study (Year) n; Age; Sex; Race Adolescent Intervention Parent Involvement Methods Treatment Primary Adolescent wt Parent Outcomes or Implications Related to Risk of and/or Ethnicitya Length Outcomes Relation of Parents to Role of Parents Biasb Adolescent Outcomes 4.6 times more likely to participants in drop out). Family treatment support for eating and/ or PA was unrelated to wt loss. Jelalian et al51 n = 118; 14.3 6 1.0 y; All adolescents received Both groups: parents and 16 wk Compared with baseline None reported Attendance and dietary Low

Downloaded from (2010) female sex: 68%; weekly group CBT-based adolescents in separate BMIs (CBT 1 EXER: 31.3 record completion were white: 72%–82%, LMP, randomly assigned to groups with parallel 6 3.1 BMI; CBT 1 PEAT: related to BMI African American: (1) CBT 1 EXER, (2) content; provided 31.5 6 3.5 BMI), there reduction. Parents are 11%–16%, other CBT 1 PEAT guidance on was a decrease in wt instrumental in or unknown: implementing family-level loss outcomes at 16 wk supporting adolescent 7%–10% change and supporting (CBT 1 EXER 30.0 6 3.4 session attendance and

www.aappublications.org/news positive eating and PA BMI; CBT 1 PEAT 30.0 6 could facilitate the habits in adolescents 3.8 BMI) and 12-mo completion of weekly follow-up (CBT 1 EXER diet records. Thus, it is 30.6 6 3.8 BMI; possible that parental CBT 1 PEAT 30.3 6 3.9 support facilitated the BMI); no differences by adolescent changes that treatment condition led to wt reduction. With limited or no parent data, the role of parents in treatment outcomes

byguest on September26, 2021 is unclear Sato et al52 n = 86; 14.3 6 1.0 y; See Jelalian et al51 (2010) See Jelalian et al51 (2010) 16 wk See Jelalian et al51 (2010) Decrease in parent BMI Parental wt loss and Low (2011)c female sex: 70.9%; (baseline BMI 30.4 6 6.9) involvement (including white: 76%, with no effect of parental monitoring of African American: treatment condition; own eating and exercise 15%, other or relationship between behaviors) associated unknown or decreases in parent and with adolescent BMI mixed race: 9% adolescent BMI from 0 to decrease 4mo Jelalian et al53 n = 49; 15.1 6 1.3 y; Adolescents randomly SBT: parents attended 3 16 wk Significant decrease in Increase in parental self- Targeting parent- Low (2015) female sex: 76%; assigned to (1) SBT with sessions about general adolescent BMI observed monitoring observed adolescent white: 67%, LMP and cognitive wt control strategies, across both conditions; across both conditions; communication and Hispanic: 12%, restructuring, (2) reviewed adolescent ANCOVA revealed trend parents in both parental modeling did other or unknown: SBT 1 EP progress; SBT 1 EP: for greater reduction in conditions reported not lead to better 21% parents attended wt among SBT versus increase in wt control adolescent wt separate (concurrent) SBT 1 EP participants behaviors but no outcomes. sessions focused on role (30.8 vs 31.8 mean BMI, decrease in parent BMI modeling healthy wt respectively) control practices and

ENe al et BEAN improved parent- adolescent EITISVlm 4,nme ,Spebr2020 September 3, number 146, Volume PEDIATRICS TABLE 1 Continued Study (Year) n; Age; Sex; Race Adolescent Intervention Parent Involvement Methods Treatment Primary Adolescent wt Parent Outcomes or Implications Related to Risk of and/or Ethnicitya Length Outcomes Relation of Parents to Role of Parents Biasb Adolescent Outcomes communication about wt- related behaviors Hadley et al54 n = 38; 15.1 6 1.3 y; See Jelalian et al53 2015 See Jelalian et al53 2015 16 wk See Jelalian et al53 2015 No differences in quality of The decline in Low (2015)c female sex: 76%; mother-adolescent communication quality white: 63%, communication between related to wt loss could African American: conditions; baseline reflect increased

Downloaded from 11%, Asian communication quality adolescent autonomy, American: 3%, not related to adolescent although this is not American Indian: wt loss; decline in clear. 5%, mixed race: communication quality 8%, other or related to better wt unknown: 11% outcomes for

www.aappublications.org/news adolescents in SBT Kitzman-Ulrich n = 42; 13.3 y; female Adolescents randomly Multifamily: parents 16 wk No changes in BMIz from Changes in family Family nurturance could Unclear et al55 sex: 100%; white: assigned to (1) multifamily attended the group baseline to post nurturance (warmth and be an important (2009) 55% therapy plus sessions with intervention by group; caring) were inversely variable to target in an psychoeducation (a adolescents; psychoeducational-only related to adolescent adolescent wt loss behavioral skill–building psychoeducation: parents adolescents had greater energy intake. Family intervention. wt loss program), (2) received the energy intake decreases conflict scores worsened psychoeducation only, (3) psychoeducational than adolescents in other in participants in WLC curriculum in group conditions. multifamily therapy sessions with relative to those in the

byguest on September26, 2021 adolescents. other conditions. Mellin et al56 n = 66; 15.6 y; female Adolescents randomly Shapedown: parents 3 mo Shapedown adolescents Parent participation in 2 Parent participation in Unclear (1987) sex: 79%; white: assigned to (1) Shapedown attended 2 sessions had improvement in sessions versus 0 or 1 treatment is associated 88%, Hispanic: 8%, LMP, (2) WLC focused on strategies to relative wt at 3 mo was associated with with adolescent wt loss Asian American: support child wt loss and (29.9% 6 15%) greater adolescent wt 2%, African improve family diet, compared with controls loss American: 3% activity, and (20.1% 6 13.2%). At 15 communication skills. mo, wt change for Shapedown adolescents compared with controls was 25.15 kgd Naar-King n = 48; 14.5 6 1.6 y; Adolescents randomly Parents were involved in 6 mo MST adolescents 83% of MST families Targeting multiple systems Low et al57 female sex: 77%; assigned to (1) MST with sessions in both significantly reduced % attended treatment and including the family (2009) African American: adaptations to increase conditions (parent OW, percentage body fat, (although l.4 sessions in a more intensive 100% adolescent and family involvement not and BMI (baseline BMI: per week rather than treatment could be adherence to dietary and described further) 38.1 6 9.3 vs 7 mo BMI: 2–3 as designed), effective. exercise 37.2 6 7.9); no changes whereas no families recommendations, (2) in control groupd completed 10-wk control: Shapedown LMP Shapedown program Naar-King n = 181; 13.8 6 1.4 y; Adolescents randomly Both groups: parents 6 mo HB-MIS and OB-MIS both Greater family attendance Because both conditions Low et al58 female sex: 67%; assigned to 3 mo of (1) HB- integrated into all reduced wt from 0 to 6 was observed in HB-MIS. involved families in (2016)e MIS, (2) OB-MIS; sessions and involved in mo and reduced %OW by Those receiving home- treatment but did not 9 10 TABLE 1 Continued Study (Year) n; Age; Sex; Race Adolescent Intervention Parent Involvement Methods Treatment Primary Adolescent wt Parent Outcomes or Implications Related to Risk of and/or Ethnicitya Length Outcomes Relation of Parents to Role of Parents Biasb Adolescent Outcomes African American: rerandomly assigned for targeting relevant skills 2.96%; there were no based treatment in assess parent or family 100% next 3 mo; nonresponders and supporting their group differences. For phase 1 were more likely variables, it is unclear randomly assigned to (1) adolescent’s behavior nonresponders, both CM to be retained in phase 2 what role the caregivers CS, (2) CM; responders change; CM and CS participants compared with those had in contributing to assigned to relapse (nonresponders): parents reduced wt in phase 2, who received office- wt loss prevention received vouchers for with no differences based treatment. Those

Downloaded from delivering adolescent between conditions. receiving CM in phase 2 incentives, attending attended more sessions sessions, and monitoring than those receiving CS. youth’s daily weigh-ins Campbell- n = 136; 13 y; female See Naar-King et al58 2016 See Naar-King et al58 2016 6 mo Families with the most wt Families with parents trying Parental collaboration, Low Voytal sex: 69%; African loss worked together, to influence change persistence, 59

www.aappublications.org/news et al American: 100% had high adolescent rather than collaborate encouragement, and (2018)c,e motivation, and with adolescents had support of autonomy continued caregiver less successful wt loss. are critical to support. adolescent success. Jacques-Tiura n = 164; 13.64–13.86 See Naar-King et al58 2016 See Naar-King et al58 2016 6 mo Greater use of wt loss skills Greater attendance was Attendance in treatment is Low et al60 6 1.29–1.41 y; was associated with associated with greater important for (2019)c,e female sex: a greater reduction in % use of wt loss skills, with increasing wt loss skill 74.4%–60.4%; OW at 6 mo; no difference no group differences in use. Greater wt loss skill African American: in wt loss skill use at 6 use of wt loss skills at 6 use can improve wt 100% mo on wt change at 9-mo mo. outcomes during the

byguest on September26, 2021 follow-up treatment period. Naar et al61 n = 181; 14.3 6 1.4 y; See Naar-King et al58 2016 See Naar-King et al58 2016 6 mo Adolescents with higher N/A Higher baseline confidence Low (2019)c,e female sex: 67%; baseline confidence had appears advantageous African American: greater reduction in % for wt loss success. 100% OW, regardless of group. Older adolescents or When baseline those with lower confidence was low, baseline confidence may reduction in %OW was do better with an greater in the CM group incentive-based than the CS group. Older treatment program. adolescents had greater reduction in %OW for CM compared to CS, and vice versa for younger adolescents. Patrick et al62 n = 101; 14.3 6 1.5 y; Adolescents randomly W, WG, and WSMS: parents 12 mo No significant time or None reported N/A Low (2013) female sex: 63.4%; assigned to (1) W, (2) WG, completed adult version treatment effects on white: 18%, (3) WSMS, (4) UC of Web site–based BMIz; all treatment arms African American: program and Web reduced sedentary

ENe al et BEAN 16%, American site–based monthly behavior, but compared Indian: 1%, Asian group sessions; WG with UC group, American: 4%, parents had follow-up adolescents in W group EITISVlm 4,nme ,Spebr2020 September 3, number 146, Volume PEDIATRICS TABLE 1 Continued Study (Year) n; Age; Sex; Race Adolescent Intervention Parent Involvement Methods Treatment Primary Adolescent wt Parent Outcomes or Implications Related to Risk of and/or Ethnicitya Length Outcomes Relation of Parents to Role of Parents Biasb Adolescent Outcomes mixed race: 3%, calls and participated in showed greatest other or unknown: group counseling aimed decreases (from 4.9 to 58% at skill building to 2.8 h/d) support their adolescent’s behavior goals; parents did not

Downloaded from receive calls or text messages Resnicow n = 123; 13.6 6 1.4 y; 10 churches with adolescent Both groups: parents invited 6 mo At 6 and 12 mo, no group None reported N/A Unclear et al63 female sex: 100%; participants were to attend every other LMP differences in DBMI; (2005) African American: randomly assigned to (1) session with adolescents; adolescents who 100% high-intensity LMP with they met separately for attended .75% of

www.aappublications.org/news weekly behavioral group half of the session and sessions reduced BMI sessions over 6 mo, plus then joined daughters for more than those with a 1-d retreat, 4–6 MI calls, PA and snack ,75% attendance and a pager that sent reminders; (2) moderate- intensity LMP with 6 monthly behavioral group sessions and no calls or pagers Saelens et al64 n = 44; 14.2 6 1.2 y; Adolescents randomly HH: parents received 4 mo Significant group time None reported N/A Low

byguest on September26, 2021 (2002) female sex: 40.9%; assigned to (1) LMP (HH), information sheets in interaction from 0 to 4 white: 71%, (2) single session of mail that promoted mo; BMIz decreased for Hispanic: 16%, physician wt counseling support of adolescent HH adolescents and African American: (TC) behavior change at the increased for TC 5%, Asian same intervals as when adolescents; DBMIz American: 2%, adolescents participated stable through 7 mo; no mixed race: 7% in manualized sessions; 0- to 7-mo group TC: parent in the session differences in DBMIz Savoye et al65 n = 209; 11.9–12.4 6 Adolescents randomly Brighter Bodies: parents 12 mo Adolescents in Brighter None reported Family-based program is Unclear (2007) 2.5–2.3 y (age assigned to (1) Brighter attended nutrition Bodies decreased BMI beneficial for BMI range: 8–16 y); Bodies LMP, an intensive classes together with (21.7 vs 1.6), percentage reduction, but it is female sex: family-based program; (2) adolescents, with body fat, and total body unknown how parental 56%–68%; white: control, clinical wt separate parent fat at 12 mo, compared involvement is related to 38%–39%, African management counseling behavioral modification with controls; controls study outcomes. American: every 6 mo classes; parents increased BMI, body wt, 38%–39%, encouraged to be percentage body fat, and Hispanic: weighed; control: parents total body fat at 12 mo. 24%–26% attended their child’s obesity clinic visits and helped with goal setting n = 73; 12.5 6 1.5 y; Adolescents randomly Parents attended all 6 wk Neither parent-adolescent Parental communication Low female sex: 60%; assigned to (1) Project sessions; Project SHINE: communication nor about health behaviors 11 12 TABLE 1 Continued Study (Year) n; Age; Sex; Race Adolescent Intervention Parent Involvement Methods Treatment Primary Adolescent wt Parent Outcomes or Implications Related to Risk of and/or Ethnicitya Length Outcomes Relation of Parents to Role of Parents Biasb Adolescent Outcomes St George African American: SHINE, an interactive parents learned No significant between- parental monitoring was appears to be related to et al66 100% parent-based LMP; (2) communication skills to group differences in associated with adolescent SB. (2013) control, general health support adolescent adolescent DBMIz adolescent DBMIz. education (weekly health behavioral change; Project SHINE families content, no behavioral control: parents received increased health strategies provided) general health content behavior communication

Downloaded from and did not receive any and reduced adolescent parenting strategies SB; families with more positive communication had less adolescent SB than those with less positive communication 67

www.aappublications.org/news Steele et al n = 93; 11.6 6 2.6 y Children and adolescents PF: parents attended 10 wk Children and adolescents in None reported N/A Unclear (2012) (age range: 7–17 randomly assigned to LMP: separate sessions for both groups had BMIz y); female sex: (1) PF intervention, (2) BFI nutrition and/or PA reductions at post 59.1%; white: 71%, education and behavioral intervention and follow- African American: components; joined up (20.12 and 20.19 14%, Hispanic: together with child or BMIz units); there were 4.3%, mixed race: adolescent for summary no group differences. 4.3%, other or and goal setting; BFI: Subgroup analyses unknown: 6.5% parents attended 3 visits revealed across with their child or conditions that children –

byguest on September26, 2021 adolescent led by (7 12 y) had greater a registered dietitian and outcomes than received a self-help adolescents (13–17 y) manual Wadden et al36 n = 47; 13.8 y; female All adolescents received CA: adolescents encouraged 16 wk Adolescent wt loss was None reported Maternal involvement Low (1990) sex: 100%; African group LMP, randomly to discuss treatment with observed across appeared to be American: 100% assigned to (1) CA, (2) MCT, parents; MCT: parents conditions, with greater beneficial in short-term (3) MCS attended all sessions (not significant) wt loss adolescent wt loss, with adolescents, in MCT and MCS groups; regardless of format optional parent weekly at follow-up, 54% of weigh-ins; MCS: parents adolescents were below met separately for the baseline BMI and 46% a manualized parent were above the baseline group, received weekly BMI; across conditions reading and homework mother attendance was assignments that were positively correlated with focused on parental adolescent wt loss support and monitoring White et al68 n = 57; 13.9 6 1.4 y; Adolescents randomly Both groups: parents had 6 mo Adolescents in HIP-Teens Parent variables related to Greater parent family and Unclear

ENe al et BEAN (2004) female sex: 100%; assigned to (1) HIP-Teens, separate logins to access lost more body fat (21.0 life and family life satisfaction related African American: family-based Internet LMP; study Web site to 6 2.0) than control satisfaction were to body fat decrease in 100% complete activities behavioral condition EITISVlm 4,nme ,Spebr2020 September 3, number 146, Volume PEDIATRICS TABLE 1 Continued Study (Year) n; Age; Sex; Race Adolescent Intervention Parent Involvement Methods Treatment Primary Adolescent wt Parent Outcomes or Implications Related to Risk of and/or Ethnicitya Length Outcomes Relation of Parents to Role of Parents Biasb Adolescent Outcomes (2) Internet control, adolescents (0.38 6 3.0) strongest mediators of suggests that family general nutrition at 6 mo. adolescent wt loss. climate influences intervention success. Williamson See White et al68 See White et al68 (2004) See White et al68 (2004) 6 mo Group differences in D% Parents in HIP-Teens lost When parents are more Unclear et al69 (2004) BMI; Dwt approached more wt than controls at engaged in treatment, (2005)c significance (P = .057 and 6 mo (2.78 kg); parent adolescents may be

Downloaded from .055, respectively), and adolescent Web site more engaged. favoring HIP-Teens usage were correlated; adolescent and parent participants in HIP-Teens had greater Web site usage. 68 68 68

www.aappublications.org/news Williamson, See White et al See White et al (2004) See White et al (2004) 6 mo By 24 mo, parents and Adolescent baseline body N/A Unclear et al70 (2004) adolescents had gained wt was a significant (2006)c wt, and there were no covariate for body wt differences between change in parents. conditions. Parents in HIP-Teens lost more body wt than control parents at 6 and 12 mo but not at 18 and 24 mo. ANCOVA, analysis of covariance; BFI, brief family intervention; BMIz, BMI z score; CA, child alone; CBT, cognitive behavioral therapy; CBT 1 EXER, cognitive behavioral therapy with exercise; CBT 1 PEAT, cognitive behavioral therapy with peer-enhanced

byguest on September26, 2021 adventure therapy; CM, contingency management; CS, continued skills; FB, family-based lifestyle modification program; HB-MIS, home-based motivational interviewing skills; HH, Healthy Habits; HIP-Teens, Health Improvement Program for Teens; LCD, low-calorie diet; LMP, lifestyle modification program; MCS, mother and child separate; MCT, mother and child together; MI, motivational interviewing; MR, meal replacement; MST, multisystemic therapy; N/A, not applicable; NP, no parent participation; OB-MIS, office-based motivational interviewing skills; PA, physical activity; PCP, primary care physician; PF, Positively Fit; PO, parent-only lifestyle modification program; PP, parent participation; SB, sedentary behavior; SBT, standard behavioral treatment; SBT 1 EP, standard behavioral treatment and lifestyle modification program plus enhanced parenting; SHINE, supporting health interactively through nutrition and exercise; TC, typical care; UC, usual care; W, lifestyle modification program delivered via Web site; WG, lifestyle modification program delivered via Web site, monthly in-person group session, and follow-up calls; WLC, wait list control; WSMS, lifestyle modification program delivered via Web site and SMS texts; %BMI, BMI percentile; %OW, percentage overweight; DBMI, change in BMI; DBMIz, change in BMI z score; D%BMI, change in BMI percentile; Dwt, change in weight. a Adolescent. b Risk of bias based on the Cochrane Collaboration risk of bias tool. c Studies from a trial previously included in the table (the trial directly above the entry); reported separately if distinct outcomes related to parents were reported or if the follow-up duration or outcomes differed. d Results were based on within-group, rather than between-group, analyses. e Study was a sequential, multiple assignment, randomized trial, rather than a traditional randomized controlled trial, and was included in this review given that randomization occurs at each stage and resembles many aspects of a traditional randomized controlled trial. 13 techniques included managing the Parent Outcome Measures Interventions That Manipulated the Role of Parents home environment (eg, limiting high- Of the 23 unique trials, 9 did calorie and/or high-fat foods in the not report any parent-related We highlight here the 5 trials that home, increasing family 36,42,44,45,62–65,67 experimentally manipulated the role 36,40,42,45,47,53 outcome measures. meals), parental role Six trials reported parent of parents, given their greater modeling of health scientific rigor with respect to our 36,40,42,44,65 weight-related outcomes, such behaviors, positive as change in parent weight or central research questions, which reinforcement of weight loss goals 41,43,48,52,53,69 enhances confidence in conclusions †† BMI ; half of these and behaviors, activities to improve trials found significant decreases drawn regarding parent involvement adolescent-parent in adolescent obesity 53,55–57,66 in parent weight or BMI, and communication, and half did not. There was no clear treatment.36,43,44,48,53 involving parents in shared decision- pattern in the behavioral strategies making,55 conflict resolution,55 and Brownell et al43 and Wadden et al36 48,55,65,67,68 used for trials that resulted in goal setting. Some parent weight loss versus trials both tested a similar lifestyle interventions taught parents the that did not. In addition, of the 6 management program delivered 3 same content that adolescents were studies that measured parent ways: (1) to adolescents only, (2) to learning so parents could support weight, 2 studies found significant mother-adolescent dyads in joint their adolescent and reduce potential group sessions, and (3) to mother- 36,45,49,51,58,62,63 associations between parent and barriers. Parent group adolescent change in BMI over adolescent dyads in separate but sessions also provided opportunities 41,52 concurrent group sessions. the intervention period, 2 71 for parents to discuss successes, studies found no significant Brownell developed this concerns, and coping strategies and association,43,48 and 2 studies intervention and delivered it to to receive peer support.36,42,43,55 The a sample of white adolescents,43 did not measure associations 36 direct associations between parent between parent and adolescent whereas Wadden et al adapted the behavioral techniques and adolescent change in BMI.53,69 intervention for Black adolescents. weight outcomes were examined in Brownell et al43 found that few studies (Table 1); thus, possible Other parent-related outcome adolescents had greater weight loss mechanisms of action cannot be variables reported included family when the intervention was delivered inferred. Among the trials that found dynamics (eg, family encouragement, to mother-adolescent dyads in between- and/or within-group nurturance, conflict, and separate but concurrent group differences on adolescent weight loss, communication)46,50,54,55,59,66 sessions, concluding that the nature the parent behavioral strategies used and treatment adherence or of the parental involvement mattered. included positive satisfaction.49,56–58 For example, In contrast, Wadden et al36 found no reinforcement,36,40,42,49,53,64 adolescents with greater weight differences in child weight loss managing the home loss reported having higher between groups (with significant environment,36,40,42,45,47,51 goal levels of self-motivation and weight losses observed in all 3 setting,48,65,67,68 parent-adolescent noted that their family members groups). Moreover, the mother’s communication,51,56,57 role worked with each other to attendance appeared to be more modeling,36,40,42,44,65 teaching mutually adopt new behaviors.59 important than the format, such that parents the same content as Adolescents with less weight loss superior weight losses were observed adolescents,36,45,49,53,58 and parent reported that parents tried to among girls whose mothers had group sessions to discuss successes, influence change (eg, force, pushing) better attendance (in either treatment concerns, and coping strategies and and that parents were less engaged in arm) compared with girls whose to provide peer support.36,42,43 Of the behavioral intervention (eg, not mothers had low or no (eg, child- note, many of these same strategies interested, inconsistent).59 alone group) attendance. Although (eg, goal setting, positive Surprisingly, one study found that different sample demographics might reinforcement, and activities to a decline in parent-adolescent explain these discrepant findings, improve parent-adolescent communication quality was related to Wadden et al36 posited that the communication) were also used in better adolescent weight outcomes dynamics of the mother-child joint the trials that did not find significant for those receiving a standard group sessions could also explain differences on adolescent weight behavioral treatment,54 although St these differences; Brownell et al43 outcomes.55,62,63,66 George et al66 found no association reported that mothers and between parent-adolescent adolescents in joint group sessions communication and adolescent were “reluctant to voice negative †† Refs 18,36,40,42,46,49,51,62,64. weight change. feelings about the problems of

Downloaded from www.aappublications.org/news by guest on September 26, 2021 14 BEAN et al dealing with each other,” whereas weight might not be an effective weight loss compared to interventions Wadden et al36 reported that mother- behavioral strategy for adolescent that included parents or adolescents child joint group sessions tended to be weightloss.However,giventhesmall alone,44,48 the small sample sizes of “more animated, fun, and supportive pilot nature of this study, additional most of these studies renders findings than were meetings [with children research into parent-adolescent inconclusive. Moreover, there is even alone or mothers alone]” and that communication is warranted. less clarity about the optimal format of “children and mothers appeared parental engagement.36,43 These comfortable together in the same findings are consistent with existing group.” Importantly, both samples DISCUSSION clinical recommendations citing the were small (fewer than 38 individuals This review has identified and need for the involvement of both in the analysis samples, with no intent- described lifestyle interventions for parents and adolescents in adolescent 6,13 fi to-treat analyses conducted), limiting adolescent obesity treatment that obesity treatment. Similar ndings generalizability. Similarly, both Janicke involved parents. Across studies, were reported in a meta-analysis of 48 44 et al and Coates et al tested there was a clear shortage of details children aged 2 to 18 years that lifestyle management programs regarding parents’ specificinvolvement demonstrated small treatment effects delivered to parent-adolescent dyads in treatment and few assessments of for interventions involving parents, (in joint sessions or in separate parent outcomes. These challenges, whether targeted individually or with sessions, respectively) versus delivery coupled with the lack of diversity in the child, compared with interventions 44 9 just to adolescents or just to participant demographics, the variety without parental involvement. 48 fi parents. In both studies, the of intervention formats, and different However, ndings of the current study involvement of both parents and adolescent weight variables, make it differ from those of a recent overview adolescents, rather than just one of difficult to determine the optimal role of 6 Cochrane reviews, which these groups individually, resulted in of parents in adolescent weight loss synthesized evidence on overweight greater adolescent weight loss post treatment. As such, we discuss the and obesity treatment among children treatment, suggesting that involving results in the context of 5 important and adolescents, including parents in obesity treatment is areas for future research that offer interventions targeting behavior fi fi bene cial. Speci cally, in post hoc promise in clarifying parents’ optimal change, pharmacotherapy, and/or 48 72 analyses, Janicke et al reported that role in adolescent weight management. surgery. This review concluded that parent-only treatment was superior These include vital needs for (1) parental involvement in obesity , for children 11 years, with combined manipulating experimentally the role of treatment of children 12 years and fi treatment yielding greater weight loss parents, (2) providing greater detail on older did not signi cantly alter the $ for adolescents 11 years. parents’ specificinvolvementin overall effect estimates on weight 72 fi treatment and their adherence, (3) outcomes. These discrepant ndings In contrast to the trials described fi might be due to the variety of 53 including assessments of speci c above, Jelalian et al manipulated parent variables (eg, parent role treatment approaches (eg, intervention content such that one modeling of eating and exercise pharmacotherapy and surgical obesity group received a standard behavioral behaviors, parenting style, feeding treatment) included in the Cochrane 72 treatment, whereas the other group style, and weight), (4) examining the review, compared to the current ’ received the same treatment with an associations between parent-related review s exclusive focus on behavioral enhanced parenting component. The factors and adolescent weight lifestyle interventions. It is important enhanced parenting component was outcomes, and (5) conducting to note that how parents are involved intended to increase parental modeling additional trials with larger, more in obesity treatment likely plays fi and build parent-adolescent diverse samples and longer follow-up asigni cant role in outcomes. Based communication skills around periods. on the studies included in this review, adolescent weight control. Adolescent the optimal intervention format BMI decreased in both groups, yet Only 5 RCTs experimentally (parent-adolescent separate group there was a trend for greater BMI manipulated the role of parents in sessions versus joint group sessions) reduction and a significant decrease in adolescent obesity treatment.36,43,44,48,53 remains unclear,36,43 and maternal negative commentary among Most of these trials delivered the same intervention content emphasizing adolescents who received the standard intervention to all experimental parent-adolescent communication behavioral treatment rather than groups while manipulating the target around weight appeared ineffective behavioral treatment with an enhanced of the intervention (parent, adolescent, in reducing adolescent weight loss in parenting component. These findings or both). Although some evidence a small pilot study.53 With only suggest that emphasizing parent- suggests that parental involvement a handful of studies on which to base adolescent communication around might result in greater adolescent these conclusions, it is apparent that

Downloaded from www.aappublications.org/news by guest on September 26, 2021 PEDIATRICS Volume 146, number 3, September 2020 15 more robust RCTs that manipulate important to determine which parent- identified and the diverse nature of the ways in which parents are related behavioral strategies are investigations addressing our specific involved in adolescent obesity effectively targeted and modified research question, no a priori treatment are needed. It is also within obesity interventions. As such, registered protocol, and concerns importanttonotethatinthis we recommend that future regarding the generalizability to trials review, we examined studies interventions include specific conducted internationally or among that involved parents, but we did assessments of parent-related non–English-speaking cultures. This not systematically compare studies behavioral strategies (eg, stimulus review is strengthened by its focus on that included parents with those control, feeding styles, and role a unique, understudied population that did not. In future studies, modeling) and an examination of how (ie, adolescents) that has been investigators could consider these strategies relate to treatment previously combined with younger directly comparing RCTs involving outcomes. children or not included at all in parents with those that do not do obesity treatment review articles. We Previous research among younger so to assess support for clinical conducted a comprehensive search to children has shown that parent recommendations. identify high-quality studies (RCTs), weight change is associated with child with at least 2 independent reviewers weight change during family-based Most trials in this review did not – assessing all possible articles for obesity treatments,31,73 75 yet far less describe in detail how parents were inclusion criteria. We adhered to the is known about this association in the involved in treatment or include Preferred Reporting Items for adolescent population. In this review, measures of parents’ adherence, Systematic Reviews and Meta- only ∼20% (n = 4) of unique trials making it challenging to draw Analyses guidelines37 and rated each quantified associations between conclusions regarding the relative article for risk of bias using parent and adolescent weight change, impact of specific behavioral a standardized tool.38,39 and findings were mixed (revealing techniques on adolescent weight loss. both positive and null associations). Clinical guidelines recommend Most interventions did not include CONCLUSIONS parents’ involvement in adolescent parent weight loss as a specific obesity treatment through strategies The optimal approach to involving intervention target; rather, parents such as monitoring, limit setting, parents in adolescent obesity were encouraged to support their reducing barriers, managing family treatment is unclear because few adolescents’ weight loss goals and conflict, and modifying the home RCTs have experimentally behaviors. Two studies did report environment.13 These behavioral manipulated parent involvement. that adolescent weight loss was techniques were used in some studies There are many opportunities for greater when parents also lost included in this review, in addition to additional research to clarify the role weight.41,52 Perhaps these other strategies, such as positive of parents in adolescent behavioral associations were due to factors such reinforcement of adolescent weight weight loss trials. In future as parental role modeling of positive loss goals, shared decision-making, investigations, researchers should weight loss behaviors (eg, self- and goal setting. Interventions using thoroughly describe how parents are monitoring by using food logs),52 these parenting approaches generally involved in obesity treatment, environmental changes in the home, ’ revealed significant reductions in measure parents adherence to and/or greater parental motivation fi adolescent BMI, yet without direct intervention strategies, assess speci c and commitment to the intervention. assessment of the specific parent- parent-related behavior change For example, 3 studies in this review related behavioral strategies, it techniques and outcomes, and found that when parents were more cannot be determined if these specific examine associations between parent engaged in treatment (ie, greater interventions are effective in and adolescent weight outcomes. attendance or Web site usage), modifying these behaviors (or, Such efforts will yield knowledge that adolescents were also more subsequently, if these parent can appropriately inform clinical engaged.36,56,69 These findings behaviors are related to adolescent guidelines and ultimately improve the identify directions for future weight loss). Of the trials included in health and well-being of this research examining parent weight this review, ∼40% did not include any vulnerable population. loss and/or engagement for impact parent-related outcome measures, on adolescent weight loss within similar to an earlier review of controlled trials. adolescent obesity interventions.32 ABBREVIATION This previous review also highlighted This review is limited by the inability RCT: randomized controlled and/ a lack of specific measures of parental to conduct a meta-analysis,76 given or clinical trial involvement.32 Moving forward, it is the limited number of studies

Downloaded from www.aappublications.org/news by guest on September 26, 2021 16 BEAN et al DOI: https://doi.org/10.1542/peds.2019-3315 Accepted for publication Jun 22, 2020 Address correspondence to Melanie K. Bean, PhD, Department of Pediatrics, Children’s Hospital of Richmond at Virginia Commonwealth University, Box 980410, Richmond, VA 23298-0410. E-mail: [email protected] PEDIATRICS (ISSN Numbers: Print, 0031-4005; Online, 1098-4275). Copyright © 2020 by the American Academy of Pediatrics FINANCIAL DISCLOSURE: The authors have indicated they have no financial relationships relevant to this article to disclose. FUNDING: Funded in part by the National Institutes of Health (R21HD084930 and R01HD095910 to Dr Bean and 2T32CA093423 to Virginia Commonwealth University). Funded by the National Institutes of Health (NIH). POTENTIAL CONFLICT OF INTEREST: The authors have indicated they have no potential conflicts of interest to disclose.

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Downloaded from www.aappublications.org/news by guest on September 26, 2021 PEDIATRICS Volume 146, number 3, September 2020 19 Parent Involvement in Adolescent Obesity Treatment: A Systematic Review Melanie K. Bean, Laura J. Caccavale, Elizabeth L. Adams, C. Blair Burnette, Jessica Gokee LaRose, Hollie A. Raynor, Edmond P. Wickham III and Suzanne E. Mazzeo Pediatrics originally published online August 24, 2020;

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Downloaded from www.aappublications.org/news by guest on September 26, 2021 Parent Involvement in Adolescent Obesity Treatment: A Systematic Review Melanie K. Bean, Laura J. Caccavale, Elizabeth L. Adams, C. Blair Burnette, Jessica Gokee LaRose, Hollie A. Raynor, Edmond P. Wickham III and Suzanne E. Mazzeo Pediatrics originally published online August 24, 2020;

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