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1 PHYSICAL ACTIVITY IN RURAL OVERWEIGHT YOUTH: A SOCIAL APPROACH By SHANA L. SCHUMAN A THESIS PRESENTED TO THE GRADUATE SCHOOL OF THE UNIVERSITY OF FLORIDA IN PARTIAL FULFILLMENT OF THE REQUIREMENTS FOR THE DEGREE OF MASTER OF SCIENCE UNIVERSITY OF FLORIDA 2011
2 2011 Shana L. Schuman
3 ACKNOWLEDGMENTS I would like to thank my family for continuing to support my academic endeavors with love and encouragement. I thank my mentor and the members of the Pediatric P sychology Lab for providing the guidance that allowed me to reach this milestone. career in pediatric psychology.
4 TABLE OF CONTENTS page ACKNOWLEDGMENTS ................................ ................................ ................................ .. 3 LIST OF TABLES ................................ ................................ ................................ ............ 5 ABSTRACT ................................ ................................ ................................ ..................... 6 CHAPTER 1 INTRODUCTI ON ................................ ................................ ................................ ...... 8 2 METHODS ................................ ................................ ................................ .............. 19 Participants ................................ ................................ ................................ ............. 19 Procedures ................................ ................................ ................................ ............. 19 Measures ................................ ................................ ................................ ................ 20 Social Experience Questionnaire ................................ ................................ ..... 20 Social Skills Improvement System R ating Scales (SSIS RS) (Stude nt Report) ................................ ................................ ................................ .......... 20 Weight Status ................................ ................................ ................................ ... 21 Physical Activity ................................ ................................ ................................ 21 Demographic Questionnaire ................................ ................................ ............. 22 Data Analysis ................................ ................................ ................................ .......... 23 3 RESULTS ................................ ................................ ................................ ............... 24 4 DISCUSSION ................................ ................................ ................................ ......... 36 LIST OF REFERENCES ................................ ................................ ............................... 44 BIOGRAPHIC AL SKETCH ................................ ................................ ............................ 54
5 LIST OF TABLES Table page 3 1 Demographic Characteristics of the Sample ................................ ...................... 29 3 2 Child Report of Social Skills ................................ ................................ ................ 30 3 3 Behavior Levels Corresponding to Total Standard and Subscale Raw Scores for the SSIS Student Form ................................ ................................ ................. 30 3 4 Mean Differences in Social Skills (Total and Subscale Scores) Among Child Gender and Race ................................ ................................ ............................... 31 3 5 Associations of Child Age and BMI z with Social Skills (Total and Subscale Scores) ................................ ................................ ................................ ............... 32 3 6 Physical Activity Descriptive Data ................................ ................................ ....... 32 3 7 Mean Differences in Sedentary and Physical Activity (PA) among Child Gender and Race ................................ ................................ ............................... 33 3 8 Associations of Child Age and BMI z with Physical Activity at Different Levels of Intensity ................................ ................................ ................................ .......... 33 3 9 Social Skills in Relation to Average Daily Minutes Spent in Physical Activity ..... 34 3 10 Child Report of Peer victimization and Prosocial Support (Social Experience Questionnaire) ................................ ................................ ................................ .... 34 3 11 Interaction Between Peer Victimization (PV) and Social Skills in Relation to Average Daily Minutes Spent in Physical Activity ................................ ............... 35 3 12 Interaction Between Peer Victimization (PV) and Peer Social Support in Relation to Average Daily Minutes Spent in Physical Activity ............................. 35
6 Abstract of Thesis Presented to the Graduate School of the University of Florida in Partial Fulfillment of the Requirements for the Degree of Master of Science PHYSICAL ACTIVITY IN RURAL OVERWEIGHT YOUTH: A SOCIAL APPROACH By Shana L. Schuman May 2011 Chair: David M. Janicke Major: Psychology Participation in physical activity during childhood and adolescence is crucial as the rates of childhood obes ity continue to rise. It is imperative to identify modifiable correlates of physical activity in order to appropriately design intervention programs for at risk populations of youth. Although several correlates of physical activity have been documented, th e association between social skills and physical activity in overweight children has not yet been studied. The aims of the current study were to : (1) d escribe social skills in a sample of rural, overweight youth, (2) determine if social skills ar e associa ted with participation in physical activity and (3) examine whether social skills and social support moderate the relationship b etween peer victimization and physical activity Participants were 89 overweight or obese youths, ages 8 to 12, and their paren ts enrolled in the E FLIP for Kids Program, a treatment outcome study that addresses overweight in rural children. Children filled out questionnaires regarding social skills, social support, and peer victimization, while parents comple ted a demographic for m. Youth physical activity data was gathered using SenseWear accelerometers. Social skills of the current sample were not significa ntly different from those of a normative group of same age peers
7 Total social skills were not significantl y associated with average daily time spent in physical activity Additionally, both social skills and social support did not moderate the relationship b etween peer victimization and physical activity Future res earch sh ould continue to examine relationships between social skills and weight related be haviors in overweight children, including those who are not seeking treatment for weight management. It is important to also consider possible mediating variables, such as depression and social support, which may better explain the association between social skills and physical activity. Thus, longitudinal research is warranted in this area.
8 CHAPTER 1 INTRODUCTION The prevalence of high body mass index (BMI) among children and adolescents continues to be a major public health concern in the United States, with recent data showing that approximately 31.7% of youth ages 2 to 19 years are classified as overweight or obe se (body mass index above the 85 th percentile for age and gender), while 16.9% are obese (body mass index above the 95 th percentile for age and gender) (Ogden, Carroll, Curtin, Lamb, & Flegal, 2010). These statistics are particularly troubling, as childhoo d overweight is associated with a myriad of medical complications, including t ype 2 diabetes, asthma, and orthopedic abnormalities (Ebbling, Pawlak, & Ludwig, 2002). Of even greater concern is the more immediate development of metabolic risk factors associ ated with overweight, such as insulin resistance, elevated blood lipid levels, increased blood pressure, and impaired glucose t olerance (Sinha e t al., 2002; Freedman, Srinivasan, & Berensen, 2007; C ook, Weitzman, Auinger, Nguyen, & Dietz, 2003; Weiss et al ., 2004; Dietz, 1998; Figueroa Colon, Franklin, Lee, Aldridge, & Alexander, 1997 ), all which may enhance the risk for cardiovascular disease. Furthermore, short term morbidities associated with childhood overweight are often psychosocial in nature, and ma y include social marginalization, low self esteem, peer victimization, and poor quality of life (Dietz, 1998; French, Story, & Perry, 1995; Strauss, 2000; Strauss & Pollack, 2003). As peer appearance norms, body image, and physical fitness are becoming inc reasingly prevalent topics among youth populations, obesity may have lasting implications for child and adolescent well being (Strauss & Pollack, 2003).
9 The literature cites several factors that contribute to childhood obesity, with the simplest explanati on being an imbalance between excess energy intake and energy expenditure in the form of physical activity (Hill, 2005). Thus, recommendations for the management of childhood overweight often include safely reducing energy intake usually in combination wit h an increase of energy expenditure, which is achieved by increasing physical activity and reducing sedentary behavior ( Kirk, Scott, & Daniels, 2005 ; Krebs, Jacobson, & American Academy of Pediatrics Committee on Nutrition, 2003 ). Although reducing energy intake and maintaining adequate nutrition are necessary components of achieving a healthy weight status, participation in physical activity during childhood and adolescence is especially crucial as lifetime physical activity habits are established during this period. There are several documented health benefits associated with participation in regular physical activity, including improvements in cholesterol, glucose, and blood pressure levels, as well as increased heart and lung fu nctioning, lower body adiposity, and improved cardiovascular fitness and strength. In addition, moderate physical activity can improve self esteem and body image, enhance sleep quality, and contribute to better psychosocial well being (Huang, Sallis, & Pat rick, 2009; Strauss Rodzilsky, Burack & Colin, 2001; Sothern Loftin, Suskind, Udall & Blecker 1999; United States Department of Health and Human Services, 1999 ). On the other hand, physical inactivity has been linked to hypertension, hyperlipidemia, a nd clustered metabo lic risk in children (Andersen et al., 2006; Brage, et al., 2004; Ekelund et al., 2007). Furthermore, studies shows that physical activity is inversely associated with
10 depression, anxiety, and shyness in children and adolescents (Page & Tucker, 1994; Steptoe & Butler, 1996; Kirkcaldy, Shephard, & Siefen, 2002). Physical activity in children can be assessed using both subjective and objective methods. Subjective methods include questionnaires, interviews, activity diaries (logs), and direc t observation, while objective methods include the use of pedometry, accelerometry, heart rate (HR) mon itoring, and combined sensors (e.g HR and movement sensors ) ( Corder, Ekelund, Steele, Wareham, & Brage, 2008). Electronic monitoring has been indicated as the best method for detecting and assessing patterns of physical activity over extended periods of time, especi ally among young children who often have difficulty accurately recalling frequency, duration, and ty pe of physical activity via self report methods ( Kohl, Fulton, & Caspersen, 2000). Corder and colleagues (2008) suggest that accelerometers with physiological parameters like heart rate or temperature have the greatest potential for increasing the accuracy of energy expenditure prediction of habitual physical activity in youth At least 60 minutes of moderate intensity physical activity daily is recommended for you th in the United States (Strong et al. 2005); however, the majority of yo uth do not meet this recommendation P hysical activity data compiled from the 2003 2004 National Health and Nutrition Examination Survey revealed that the estimated prevalence of achievement of physical activity recommendations varied and ranged from 2% among 12 to15 year old non Hispanic White girls to 61% among normal weight 6 to 11 year old non Hispanic Blacks (Centers for Disease Control, NHANES 2003 2004). Given these statistics, and considering the myriad of negative health consequences associated with physical inactivit y, it is necessary to recognize and
11 understand modifiable correlates of physical activity in order to appropriately design intervention programs for identified at risk populations of youth. Kohl and Hobbs (1998) proposed that determinants of physical activ ity fall into three broad categories: psychological/social/demographic, environmental, and physiologic/developmental. Psychological factors have also been considered as distinct from those at the socio demographic level (Lindquist, Reynolds, & Goran, 1999) so taking this view one could state that there are four broad categories The role of d emographic factors (e.g., age, gender, and socioeconomic status) in physical activity has been widely studied. Data from the NHANES 2003 2004 survey revealed a signifi cant decline in physical activity as age increased, regardless of race/ethnicity, gender, SES, or weight status ( Centers for Disease Control, NHANES 2003 2004). Using accelerometry in a sample of children in grades 1 to 12, Trost and colleagues (2002) found the greatest age related differences to occur in elementary school, mor e specifically between grades 1 to 3 and grades 4 to 6 However, the largest disparities have been observed among gender, such that boys engage in more physical activity than girls (Ea ton et al., 2010 ; H eath Pratt, Warren & Kahn, 1994 ). Indeed the magnitude of gender differences may be highly dependent on the method used to assess physical activity. Trost et al. (2002) used uniaxial accelerometers to assess physical activity and reported a magnitude of gender differences that was noticeably smaller than that reported by studies using self report methods to assess physical activity, except at the level of vigorous intensity activities. Also greater participation in physical activi ty by boys may be explained by a number of other mechanisms, including differential development of motor skills (Thomas & French, 1985), differences in body
12 composition during growth and maturation (Nogueira & Macedo da Costa, 2009) and gender role expecta tions (Slater & Tiggemann, 2010). In addition, higher levels of physical activity are reported in white compared with minority populations and in children from more affluent backgrounds (Andersen, Crespo, Bartlett, Cheskin, & Pratt, 1998; Bradley, McMurray Harrell, & Deng, 2000). These findings are not surprising, as low income youth typically have less access to recreational facilities including parks, fitness clubs, sports fields, and trails (Estabrooks, Lee, & Gyurcsik, 2004; Powell, Slater, & Chaloupka 2004). In fact, literature has suggested that children and adolescents who live in areas with more direct access to recreational facilities and programs are more active than those who do not have such access (Sallis, Prochaska, & Taylor, 2000). Low level s of physical activity have been observed in rural youth compared with their urban counterparts, as many of the identified environmental supports for physical activity in urban areas such as sidewalks, street connectivity, population density and diversity of land use (Kirtland et al., 2003; Saelens, Sallis, & Frank, 2003) are not applicable to rural residents. Finally, physical activity is positively associated with self efficacy and attitudes toward exercise and negatively associated with perceived barri ers, including time constraints, a lack of resources, lack of support from parents, and self consciousness when exercising (Gray Janicke, Ingerski, & Silverstein 2008), with females and older children reporting higher levels of barriers (Allison, Dwyer, & Makin, 1999; Zabinski, Saelens, Stein, Hayden Wade, & Wilfley, 2003). Regardless of weight status, children who report more barriers are less likely to be physically active (Sallis, Prochaska, & Taylor, 2000; Allison, Dwyer, & Makin, 1999; Ga rcia et al., 1995).
13 Along with the recent emergence of group based weight management programs, there has been increased attention on the role of social functioning as it relates to healthy lifestyle behavi ors among overweight youth, more specifically physical activity participation. Social functioning is a fairly vague term that is best defined as an index of social competence, a nd social emotional adjustm ent (Adams Streisand, Zawacki, & Joseph, 2002). Research suggests that social functioning in children predicts changes in adiposity ( Lemeshow et al. 2008 ) and other weight related behaviors over time (e.g., television viewing and sports participation) (S trauss & Pollack, 2003), with much of the literature emphasizing the role of social support in physical activity. Social support provid ed by either parents or peers has been positively associated with youth involvement in physical activity (Sal lis et al., 2000 ). However, as children age an increasing amoun t of time is spent with friends rather than family, highlighting the importance of peer influence on physical activity. Peer support offers opportunities for companionship, social integration, and the deve lopment of physical abilities and socio emotional competencies (Salvy et al., 2008). In addition, emotional support from peers may enhance self worth, thereby increasing self efficacy to perform a variety of physical activities and to overcome perceived ba rriers (Duncan, Duncan, & Strycker, 2005; Duncan, 1993). In contrast, impaired social functioning may exacerbate overweight by promoting sedentary activities or increasing unhealthy eating behaviors (e.g., overeating to cope with loneliness) ( Braet & Van Strein, 1997; Salvy, Coelho, Kieffer, & Epstein, 2007) Studies have found that high social problems are associated with less participation in
14 physical activity (Kirkcaldy, Shephard, & Seifen, 2002). Of particular concern, research has shown that socially impaired youth may be less successful in weight control interventions (Epstein, Wisniewski, & W e ng, 1994). Wilfley and colleagues (2007) recently conducted a randomized control trial comparing different family base d weight maintenance approaches, including o ne intervention that targeted factors identified as body image). They found that children with low social problems in this intervention achieved the best weight ch ange outcomes from b aseline to two year follow up, while n o condition based differences were found among chil dren with high social problems. These results are concerning, given that overweight children are at increased risk for a variety of psychosocial problems, including peer victimization, social isolation, and poor self esteem (Schwimmer, Burwinkle, & Varni, 2003; Strauss & Pollack, 2003; Zametkin, Zoon, Klein, & Munson, 2004 ). However, certain indices of social functioning, incl uding social support and social skills, ma y allow children to overcome these problems. For instance, s ocial skills can be used to limit negative aspects of social relationships and mobilize social support for engaging in healthy lifestyle behaviors (Dierk et al., 2006). While social functioning is a broad concept, social skills are a set of specific behaviors that are often included in this domain. Gresham and Elliott (2008) define simultaneously discouraging negative in teractions when applied to appropriate social Social skills allow an individual to successfully complete social tasks, including peer group entry, initiating and sustaining a conversation, making friends, and pla ying a game with peers (Gresham Elliott, Cook, Vance, & Kettler 2010). R esearch
15 has shown that social skills deficits in children are associated with poor academic performance, later social adjustment problems, as well as a variety of negative psychological outcomes, including peer vi ctimization and depressive symptoms (Cowen Pederson, Babigian Izzo, & Trost 1973; Deater Deckard, 2001; Hay, Payne, & Chadwick, 2004; Masten, 2005; Segrin, 2000) ; however, there is a paucity of research examining the relationship between social skills a nd physical activity in overweight youth. Prior research has primarily utilized broadband measures, such as the Child Behavior Checklist, as a screener for general social problems (Goldschmidt et al., 2010; Wilfley et al., 2007; deNiet Timman, Jongejan, P asschier, & van den Akker 2010). While somewhat informative, these broadband measures are often limited. For example, the Social Problems subscale on the Child Behavior Checklist includes items, Thus, these measures are limited in informing researchers as to why certain children exhibit or experience problematic outcomes, and in prov iding specific targets for intervention. On the other hand, a widely used measure that specifically assesses social skills is the Social Skills Rating System (SSRS; Gresham & Elliott, 1990). The SSRS has been used in studies of children with epilepsy, high functioning autism, attention deficit disorder and 22q11 deletion ( Tse, Hamiwka, Sherman, & Wirrell, 2007; Macintosh & Dissanayake, 2006; Mulhern et al., 2004 ; Kiley Brabeck & Sobin, 2006). Given that overweight children have been shown to experienc e more interpersonal difficulties, it is necessary to identify modifiable ways to reduce these
16 problems. While a focus on negative behaviors initiated by peers (e.g., bullying, teasing, and ostracization from activities) is necessary, it is also imperative to identify social skills that may serve to reduce these negative social experiences and promote participation in more positive health behaviors. For example, the ability to engage in conversation, assert oneself, join an activity already in progress, and emotions when feeling angry or upset, may be important tools for a child to have when confronted with barriers to physical activity, including lack of support or peer victimization. For children who are overweight, these social skills may be taught and consolida ted within a group based weight management program, especially considering that children with social problems may lack the basic skills needed to enlist social support for engaging in healthy behaviors (Wilfley et al., 2007). Moreover, it is unclear to what extent children who are overweight experience social skills deficits O nly one study has used a standardized measure specific to social skills to assess social skills in an overweight population (Lumeng et al., 2010). While this stud y found social skills to be generally within the average range, further research describing social skills in overweight youth is clearly warranted. Thus, t he first aim of the current study is to describe social skills in a treatment seeking sample of rura l overweight and obese youth as they vary by age, gender, race, and weight status. Given that children who are overweight experience more weight related victimization and social marginalization, it is hypothesized that children will report lower social ski lls than a norma tive sample of same age peers. Based on previous findings, it is expected that there will be a significant gender difference in social skills, such that on average, females will have higher social skills ratings than males.
17 Adding to the li terature on social problems in overweight youth, this study seeks to use a standardized measure the Social Skills Improvement System Rating Scales, to gather information specific to social skills behaviors. The social skills domain of this questionnaire a ssesses behaviors within the following seven sub domains: communication, cooperation, assertion, responsibility, empathy, engagement and self con trol, and also provides a total social skills score (Gresham & Elliott, 2008). Using physical activity data f rom accelerometers, the current study also seeks to investigate the association between social skills and average daily minutes spent in physical activity. Overweight children who have social problems may be at a disadvantage if they lack the appropriate s ocial skills needed to enlist support for engaging in healthy behaviors, such as physical activity. Thus, it is expected that children who report higher social skills will spend more time in physical activity. The third aim of the study is to determine if social support and social skills moderate the relationship between peer victimization and average daily minutes spent in physical activity Peer victimization has been positively associated with barriers to physical activity and inversely associated wit h child reported physical activity in a sample of treatment seeking overweight youth (Gray et al., 2008). However, given that social support provid ed by peers has been positively associated with youth involvement in physical activity (S allis et al., 2000), is expected that peer social support will moderate the relationship between peer victimization and physical activity. Likewise, children who are able to use social skills (e.g., asserting oneself and exhibiting self control when teased) may be less likely to withdraw from social situations, including
18 physical activity. Thus, it is hypothesized that social skills will also moderate the relationship between peer victimization and physical activity Aims and Hypotheses Aim 1: T o describe social skills in a treatment seeking sample of overweight and obese youth as they vary by age, gender, race, and weight status. Hypothesis 1a: Overweight children will report lower social skills than a normative sample of same age peers. Hypot hesis 1b: Females will report higher total social skills scores than males. Aim 2: To examine the association between child reported social skills and average daily time spent in physical activity. Hypothesis 2 : Children who report higher total social ski lls will engage in more average daily minutes of physical activity. Aim 3: To examine peer social support and social skills as separate moderating variables in the relationship between peer victimization and average daily time spent in physical activity. Hypothesis 3a: Peer social support will moderate the relationship between peer victimization and physical activity. Hypothesis 3b: Social skills will moderate the relationship between peer victimization and physical activity.
19 CHAPTER 2 METHODS Partic ipants One hundred and seventy one children between the ages of 8 and 12 were recruited from six different rural counties for a family based healthy lifestyle treatment outcome program. Children were eligible to participate if they were between the ages of 8 and 12, accompanied by a parent or legal guardian, resided in a designated rural county, and had a BMI above the 85 th percentile for age and gender. Individuals who had a severe developmental delay, were enrolled in another weight loss program, or had a serious medical condition that would limit participation in physical activity were excluded from the study. Procedure s Children were recruited using direct solicitation methods, including mailing brochures to households using commercially available mailing lists, as well as distributing information through local schools libraries, churches, health care providers, and community organizations Finally, press releases were made via local radio stations and newspapers. Inter ested families were asked to call a toll free number to receive more information about the program and complete an initial phone screen. Eligible families then completed an in person screening visit at their local University of Florida IFAS Extension offic e After families were provided with a complete study description, informed consent and assent were obtained from the both the child and parent prior to the administration of questionnaires. These initial in person screening visits occurred approximately o ne to two months prior to the start of treatment. Families also completed
20 s With the exception of the accelerometry data, all measures were completed during th e initial in person screening visit. Families who attended combined appointments were not asked to complete a select number of questionnaires due to time constraints. Physical activity data was collected via accelerometry during the first week of treatment. Measures Children completed the following measures: Social Experience Questionnaire Child self report of peer victimization and peer so cial support was obtained using the Social Experience Questionnaire (Crick & Gro t peter, 1996). This 15 item measure consists of three subscales (i.e. relational victimization, overt victimization, and receipt of prosocial behavior) consisting of five items each. For the purpose of this study, the relational and overt victimization subscales were combined to form a total victimization scale. The prosocial behavior scale was used to describe peer social support. Children rate items on a 5 point Likert scale, ranging from 1 = never to 5 = all the time with higher scores indicating increased frequency of behavior. for the total good internal consistency. Social Skills Improvement System Rating Scales (SSIS RS) (Student Report) Children also completed a shortened Student Form of the Social Skills Improvement System Rating Scales (SSIS RS; Gresham & Elliott, 2008). The SSIS RS student form assesses three d omains including social skills, problem behaviors, and academic competence. Children answered 75 questions related to both social skills and
21 problem behaviors; however, f or the purpose of this study, only social skills behaviors were included in analyses. This domain includes common social skills behaviors in the following sub domains: communication, cooperation, assertion, responsibility, empathy, engagement, and self con trol. Each statement on the SSIS is answered on a 4 point Likert scale that requires the respondent to indicate to what degree a statement is true for him or her (1= not true to 4= very true ) sample. High internal consistency (.94) and test retest reliability (.81) have also been reported in the SSIS normative sample of same age peers. This measure has also demonstrated good criterion related and construct validity (Gresham & Elliott, 2008). Weight Status Child h ei ght and weight were obtained by the project nurse or health technician Height was measured using a Harpendon stadiometer, and weight was assessed using a Tanita BWB 800 Digital Medical S cale. These data were used to calculate B ody Mass Index ( kg/m 2 ). Bo dy Mass Index z score (BMI z ) values were then calculated for children using age in months, gender specific median, standard deviation, and the Box Cox transformation according to Center for Disease Control national norms ( Kuczmarski et al., 2002). Physical Activity T ime spent in physical activity w as assessed using the SenseWear Armband (BodyMedia, Inc., Pittsburgh, PA). Children were instructed in proper usage of the SenseWear Armband, and members of the research team assisted children in attachi ng the SWA body monitor to the back of the left arm, over the triceps muscle. Children were asked to wear the device 24 hours a day, for seven consecutive days in between the first and second treatment sessions. Families were asked to not make any
22 changes to typical physical activity patterns until after session two. The SenseWear armband technolog y includes a two axis accelerometer device that measures motion generated from both the upper and lower body. In addition to motion detection, this device uses h eat related sensors that allow for the assessment of complex, non ambulatory activities. These sensors can also detect the increased work required to walk up a grade or to carry a load (McClain Welk, Wickel, & Eisenmann, 2005). This instrument has been shown to accurately estimate energy expenditure for most activities in children (Calabro, Welk, & Eisenmann, 2009; Arivdsson Slinde, & Hulthen, 2009). For the purpose of the current study, physical activity data was analyzed if children had at least 16 ho urs of wear time per day, for at least four days (three weekdays and one weekend day). Data was obtained using SenseWear Professional Software, Version 7.0. Time spent in physical activity was reported in average minutes per day. The intensity of physical activity was described as metabolic equivalents (METs). Time spent in activity that rated as 3 to 5.9 METs was classified as moderate physical activity, and time spent in activity rated as above 6 METs was classified as vigorous physical activity. Parents or guardians completed the following questionnaire: Demographic Questionnaire Parents and guardians completed a self report demographic questionnaire Information on p arent and child age, gender, and race, as well as parent marital status, income, occupat ional status and highest level of education was obtained. Parents also completed this form at the screening assessment.
23 Data Analysis Descriptive statistics (means, SDs) were calcula ted for demographic variables, child reported social skills, social supp ort and peer victimization as well as total time spent at various levels of sedentary and physical activity. Next, a one sample t test was calculated to investigate whether child reported total social skills were significa ntly different from those of a s ame age normative sample. Independent samples t tests were conducted to determine differences in social skills between males and females and also among Caucasian and minority racial groups. Correlation analyses were then used to examine the relationship b etween child characteristics (age and weight status), and social skills. A separate set of correlations and independent samples t test analyses were run to determine any differences in physical activity by child age, weight status, gender, and race/ ethnicity. The association among social skills and physical activity was then assessed using hierarchical regression analyses Demographic variables that were correlated with total time spent in physical activity were entered in block 1, while the child re ported total social skills standard score was entered in block 2. Multiple regression using centered main effects was conducted to test social skills and social support as moderating variables in the relationship between peer victimization and physical act ivity.
24 CHAPTER 3 RESULTS Overall, a total of 171 children completed questionnaires at the ir initial in person screening visit. Unfortunately, 25 participants withdrew from the program or were assumed to be no longer interested prior to the first treatme nt session. Thus, 146 children began treatment. Accelerometers were provided to children at the first group treatment session, and returned to researchers one week later at the second treatment session. Of the 146 children who initiated treatment, 44 did not have sufficient physical activity data. Eight children did not return the accelerometer, while 36 did not wear the accelerometer for at least 16 hours per day on at least three weekdays and one weekend day. An additional 12 children did not complete the Social Skills Improvement System, because they only were required to attend a combined screening and baseline assessment due to signing up for the program within two weeks of the treatment start date. Thus, a total of 90 children had sufficient physical activity data and complete d the Social Skills Im provement System. Finally, o ne participant was considered to be an outlier with regard to total time spent in moderate physical activity Because this individual participated in an exceptionally high amount of moderate physical activity, their average dail y minutes spent in total physical activity was more than three standard d eviations above the sample mean. Thus, t his participant was subsequently removed from analyses The remainder of participants ( N = 89) had both sufficient physical activity and social skills data and were included in analyses.
25 Children were aged 8 to 12 years ( M = 10.57, SD = 1.40), with 60.7% of participants identifying as Caucasian, and a smaller percentage of children identifying as African American (14.6%), Bi or Multi Racial (9.0%), and Hispanic (6.7%). Approximately 89% of the children were obese and 11% were overweight. Slightly more than half (53.9%) of the participants were female. Median family income was reported to be between $40,000 and $59,000. Demographic inf ormation is displayed in Table 3 1. The first aim of the study was to describe social skills in a sample of treatment seeki ng overweight and obese youth. Results from the Student Form of the Social Skills Improvement System (SSIS) showed that, on average, children reported total social skills in the average range ( M = 100.51, SD = 15.80), based on the normative distribution from the SSIS (see Table 3 2 for means and standard deviations of total social skills and subscale scores). Ap proximately 16% of children reported total social 1 to 2 SD below the normative 2 SD b elow the normative mean). Table 3 3 displays behavior levels (e.g., below average, average, and above average) corresponding to total and subscale raw scores for the Student Form of the Social Skills Improvement System. Results from a one sample t test rev ealed that mean total social skills were not significantly different from those of the same age SSIS normative sample, [ t (88) = .302, p = .763]. Additional t tests did not reveal any significant differences in subscale scores between this sa mple and the no rmative sample. Next, independent samples t tests were run to determine if there were gender differences in social skills. While total social skills did not differ by gender ( p =.280), males reported significantly lower scores on the
26 Cooperation ( p = .032) and Responsibility ( p = .045) subscales. The Cooperation and directions, while the Responsibility subscale includes behaviors such as doing well behaved, and showing regard for property or work. To determine if there were differences in social skills by race, an independent samples t test was conducted, using Caucasian and racial/ethnic minority subsamples. Results did not reveal any signifi cant differences in social skills by race. Finally, bivariate correlations were conducted to determine differences in social skills by age and BMI z score. Again, using child reported total social skills, findings revealed that older children reported lowe r total social skills ( r = .225, p < .05) T here was no significant association between BMI z and total social skills. Th ese results are shown in Tables 3 4 and 3 5 The second aim of the study was to examine the relationship between child reported social skills and average daily minutes spent in physical activity. Prior to examining this relationship, descriptive analyses were run to obtain average total time spent in daily physical activity, as well as average daily time spent in moderate (3 to 6 METs) a nd vigorous (>6 METs) physical activity. This data is displayed in Table 3 6 In addition, analyses were run to determine if any characteristics of the child (e.g., age, gender, race, and BMI z ) were significantly related to time spent in physical activity Independent sample t tests revealed that on average, males spent significantly more time in total, moderate, and vigorous physical activity, while females spent significantly more time in sedentary activity. A second independent samples t test did not r eveal significant differences in physical activity by race, and bivariate correlations did not reveal any significant differences in physical activity by child age or BMI z score (see
27 Tables 3 7 and 3 8 ). Thus, only child gender was entered as a covariate in subsequent multiple regression analyses. Lastly, a square root transformation was applied to total time spent in physical activity, as the data were significantly and positively skewed ( z = 3.65). Findings from a multiple regression analysis revealed that although the overall model was significant, ( F (2, 87) = 5.00 p =.009), the main effect of social skills was not associated with average daily time spent in physical activity t (86) = .702, p = .485. Child gender accounted for 9.9% of the variance in th is model, while child reported social skills only added to 0.5% of the total variance. These results are presented in Table 3 9 Although not initially proposed as an aim of the study, post hoc analyses were conducted to determine if social skills were as sociated with physical activity at different levels of intensity. Two separate multiple regression analyses were run, controlling for gender, with moderate physical activity and vigorous physical activity as dependent variables. There was no significant as sociation between social skills and average daily minutes spent in moderate physical activity ( p = .520); however, the relationship between social skills and average daily minutes spent in vigorous physical activity was trending toward significance ( p = .0 90). There was no association between social skills and sedentary activity ( p = .878). The third aim of the study was to determine if social skills or social support moderated the relationship between child reported peer victimization and average daily mi nutes spen t in physical activity. T able 3 10 deviations for the Social Experience Questionnaire. To examine these relationships, two separate multiple regression analyses were run, using centered main effects (Preacher,
28 Curran, & Bauer, 2006 ) and controlling for child gender. Both social skills and social support did not moderate the relationship between peer victimization and total time spent in physical activity. Also, contrary to previous findings in the li terature ( Storch et al., 2007; Faith, Leone, Ayer s, Moonseong, & Pietrobelli, 2002 ), peer victimization was not associated with average daily minutes ti me spent in total physical activity. These r esults are presented in Table s 3 11 and 3 12
29 Table 3 1. De mographic characteristics of the s ample Mean SD Child Age 10.57 1.40 BMI z score 2.13 0.42 % Gender Boys 46.1 Girls 53.9 Child Race Caucasian 60.7 African American Bi racial 14.6 9.0 Hispanic 6.7 Asian Native American 1.1 1.1 Not Reported 6.8 Median Family Income Below $19,999 13.5 $20,000 $39,999 31.5 $40,000 $59,999 23.6 $60,000 $79,000 16.9 $80,000 $99,999 6.7 Over $100,000 Not Reported 5.6 2.2
30 Table 3 2 Child report of social s kills Mean SD Possible Range Social Skills Improvement System ( Student Form ) a Total Social Skills 100.51 15.80 0 138 Communication 13.73 3.27 0 18 Cooperation 16.89 3.62 0 21 Assertion 14.25 4.42 0 21 Responsibility 15.45 3.87 0 21 Empathy 14.09 3.46 0 18 Engagement 15.07 4.12 0 21 Self Control 10.81 4.49 0 18 a Higher scores indicate better social skills Total Social Skills represented as a standard score; subscales represented as raw scores Table 3 3. Behavior levels corresponding to total standard and subscale raw s cores for the SSIS Student Form Below Average Average Above Average Social Skills Improvement System ( Student Form ) a Total Social Skills <85 85 115 >115 Communication 0 10 11 17 18 Cooperation 0 12 13 20 21 Assertion 0 9 10 18 19 21 Responsibility 0 11 12 19 20 21 Empathy 0 9 10 17 18 Engagement 0 11 12 19 20 21 Self Control 0 6 7 15 16 18 a Higher scores indicate better social skills Total Social Skills repr esented as a standard score; subscales represented as raw scores
31 Table 3 4. Mean differences in social skills (total and s ubscale scores) a mong child gender and r ace Child Gender Male ( n = 41) Female ( n = 48) M SD M SD Total Social Skills 98.54 16.34 102.19 15.29 Communication 13.27 3.20 14.13 3.31 Cooperation 16.00* 3.96 17.65 3.14 Assertion Responsibility Empathy Engagement Self Control 13.76 14.56* 13.63 14.83 11.56 4.65 4.05 3.64 4.35 4.18 14.67 16.21 14.48 15.27 10.17 4.21 3.58 3.28 3.95 4.68 Child Race Caucasian ( n = 54) Racial and/or Ethnic Minority ( n = 34) M SD M SD Total Social Skills 102.72 16.71 96.59 13.70 Communication 13.96 3.44 13.29 3.01 Cooperation 17.33 3.77 16.12 3.31 Assertion Responsibility Empathy Engagement Self Control 14.91 15.98 14.35 15.46 11.31 4.34 4.07 3.50 4 36 4.66 13.03 14.59 13.62 14 .29 10.00 4.31 3.47 3.43 3.63 4.21 p < .05. ** p < .01.
32 Table 3 5. Associa tions of child a ge and BMI z with s o cial skills (total and s ubscale s cores) r p Age Total Social Skills .225 .034* Communication .191 .073 Cooperation .250 .018* Assertion Responsibility Empathy Engagement Self Control .121 .068 .213 .227 .178 .260 .529 .045* .033* .095 BMI z Total Social Skills .097 .367 Communication .041 .704 Cooperation .144 .179 Assertion Responsibility Empathy Engagement Self Control .035 .069 .139 107 .095 .742 .519 .192 .317 .378 p < .05. ** p < .01. Table 3 6. Physical a c tivity descriptive d ata Mean SD Minimum Maximum Sedentary a 1235.60 109.18 836.75 1385.50 a 111.90 52.72 29.25 271.50 Moderate (3 6 METS) a 106.67 48.21 27.75 248.00 Vigorous (> 6 METS) a 6.02 9.53 0.00 70.75 a Units represent average time in minutes per day
33 Table 3 7. Mean differences in sedentary and physical activity (PA) among child gender and r ace Child Gender Male ( n = 41) Female ( n = 48) M SD M SD Sedentary 1205.54* 117.22 1261.27 95.72 Total PA 129.99** 58.01 96.45 42.56 Moderate 121.52** 51.81 93.98 41.35 Vigorous 8.51* 12.54 3.88 5.09 Child Race Caucasian ( n = 54) Racial and/or Ethnic Minority ( n = 34) M SD M SD Sedentary 1217.62 123.49 1261.46 76.29 Total PA 116.06 57.02 106.21 45.82 Moderate 111.78 52.96 99.39 39.62 Vigorous 5.54 6.51 6.86 13.14 p < .05. ** p < .01. Table 3 8. Associations of child a ge and BMI z with physical a ctivity at different levels of i ntensity r p Age Sedentary .131 .221 Moderate .173 .105 Vigorous .085 .427 Total .127 .234 BMI z Sedentary .037 .733 Moderate .067 .532 Vigorous .064 .553 Total .093 .388 p < .05. ** p < .01.
34 Table 3 9 Social skills in r elation t o average daily minutes spent in physical a ctivity B SE B Step 1 Constant 12.655 .802 Child Gender 1.532 .495 .315** Step 2 Constant 11.598 1.707 Child Gender 1.573 500 .323** SSIS Total Social Skills 011 016 .072 p < .05. ** p < .01. 2 = .104 Table 3 10. Child report of peer victimization and prosocial s upport (Social Experience Questionnaire) Mean SD Range Total Peer Victimization a 20.62 8.80 10 50 Overt Victimization a 10.15 5.15 5 25 Covert Victimization a 10.47 4.27 5 25 Peer Prosocial Support b 17.93 4.60 5 25 a higher scores indicate more victimization b higher scores indicate more prosocial support
35 Table 3 11. Interaction between peer victimization (PV) and social s k ills in relation to average daily minutes spent in physical a ctivity B SE B Step 1 Constant 12.655 .802 Child Gender 1.532 .495 .315** Step 2 Constant 12.924 .827 Child Gender 1.703 515 .350** SEQ Total PV .039 030 .139 SSIS Total Social Skills 007 016 .048 Total PV* Total Social Skills .000 .002 .004 p < .05. ** p < .01 2 = .122 Table 3 12. Interaction between peer victimization (PV) and peer social support in relation to average daily minutes spent in physical a ctivity B SE B Step 1 Constant 12.655 .802 Child Gender 1.532 .4 95 .315** Step 2 Constant 13.086 .829 Child Gender 1.711 .509 .351** SEQ Total PV .021 033 .077 SEQ Peer Support .009 .060 .018 Total PV Peer Support .009 .006 .160 p < .05. ** p < .01. 2 = .142
36 CHAPTER 4 DISCUSSION As the prevalence of obesity among youth in the United States remains relatively unchanged over the past five years (Ogden et al., 2010), comprehensive prevention and intervention efforts to address healthy lifestyle behaviors have become more widespread. Given that the majority of overweight children are not meeting recommendations for physical activity, initiatives aimed at increasing youth participation in physical activity are w arranted. There is a particular need for research to identify modifiable factors associated with youth involvement in physical activity, especially as lifetime physical activity habits are often established during this period (Janz, Dawson, & Mahoney, 2000 ; Tammelin, Nayha, Hills, & Jarvelin, 2003). Unfortunately, overweight children tend to experience more social difficulties than their non overweight peers, most notably peer victimization and social isolation (Hayden Wade et al., 2005; Strauss & Pollack, 2003). These negative interactions have been shown to increase barriers for engaging in healthy behaviors, particularly physical activity (Gray et al., 2008). Although several aspects of social functioning (e.g., teasing, friendship nomination, social sup port) have been widely studied in relation to youth participation in physical activity (Faith et. al, 2002; Storch et al., 2007, S trauss & Pollack, 2003; Sallis et al., 2000), there is a lack of research examining the association between social skills and physical activity. To date, only one study has assessed social skills in an overweight population of youth using a well validated measure specific to social skills (Lumeng, et al., 2010) and there is no research that has examined the relationship between s ocial skills and physical activity. This study serves to extend current literature on social functioning and physical activity in overweight children by
37 incorporating a well validated measure to describe social skills in a rural population of treatment see king overweight youth, utilizing objectively measured accelerometry data to assess physical activity, and examining the association between social skills and physical activity. The first aim of this study was to describe self reported social skills in thi s treatment seeking population of youth. Although total social skills w ere not significantly different for males and females, males reported significantly lower scores on the Responsibility and Cooperation subscales. There was also an unexpected significan t difference in total social skills by age, such that older children reported lower total social skills. Most importantly, c hildren in this sample reported social skills in the average range when compared to published norms. This finding does not support the initial hypothesis that overweight and obese children would report lower social skills scores than a healthy sample of same age peers. There are a number of possible reasons for this finding. It may be that many overweight children have adequate socia l skills, but continue to exhibit limited social functioning due to other factors, including lack of social support and peer victimization (e.g., weight related teasing). However, this sample of youth actually did not report high levels of peer victimizati on or low peer support. In fact, children in this study appear to be functioning quite well from a social perspective. Thus, one might hypothesize that overweight children who have low social skills did not opt to participate in this program, as it involve d significant interaction with same age peers in a group setting. Children may also not have been able to accurately assess and report their social skills. For example, age and developmental factors may have resulted in considerable variability with regard to how well children were able to perceive their own
38 limitations. This hypothesis is substantiated by the fact that older children reported significantly lower total social skills scores than younger children. Also, it is possible that children in this st udy who experience impairments in social functioning may have been influenced by social desirability bias and over reported the frequency of engaging in socially skilled behavior. Thus, f uture research should use data from multiple informants, including pa rents and teachers, to discern if children are accurately reporting frequency of social skill use. A second aim of the study was to examine if child social skills were related to physical activity. Contrary to what was hypothesized, no relationship was f ound between social skills and average daily minutes spent in total physical activity, after controlling for child gender. In addition, results from separate post hoc analyses revealed that social skills were not significantly associated with average daily minutes spent in sedentary, moderate, or vigorous physical activity. There are a number of possible explanations for this result. First, there may have been a selection bias based on time spent in physical activity after discounting children that did not record enough physical activity data to interpret. In this sample, a verage daily minutes spent in physical activity well exceeded the recommended amount of 60 minutes per day, which is inconsistent with previous findings suggesting that the majority of you th do not meet this recommendation. Thus, this data may not be representative of physical activity participation in the general population of same age overweight youth. Also, it is important to note that children who initiated treatment and had sufficient physical activity data had higher social skills scores, on average, compared to children who did not have sufficient physical activity data to interpret. It is possible that this trend
39 was influenced by the use of a specific cut off criterion for physical activity, which likely limited findings by reducing variability in social skills scores. Nevertheless, these findings suggest that children with lower social skills were more likely to drop out of the study before the start of the intervention. Thus, the children with lower social skills may have had lower levels of physical activity; unfortunately this is unknown. Overall, this could have important implications for children who are not able to participate in weight management treatment due to behavioral, social, or emotional difficulties. Also, it may be possible that the relationship between social skills and physical activity is better explained by other mediating factors, such as depressive sympto ms or social support. Finally, social skills may not be related to physical activity. Perhaps other domains of social functioning, including peer victimization and social support are more relevant to participation in physical activity for youth in this age group, especially considering that social skills are of ten already well developed in children of this age. A final aim of the study was to determine if child reported social skills and peer social support moderated the relationship between peer victimization and average daily minutes spent in physical activi ty. Both social skills and social support did not moderate this relationship. Also, child reported peer victimization was not associated with average daily minutes spent in physical activity. This was not expected. These findings may be explained by the fa ct that on average, this sample reported adequate social skills and social support and low levels of peer victimization. One study found that while behavioral and emotional problems were more prevalent in a sample of treatment seeking obese children compa red with a community sample of obese children social competence was higher (Braet, M ervielde, & Vandereycken, 1997). This finding, along
40 with data from the current study may suggest that children seeking weight management treatment have more social suppor t and experience less peer victimization than non treatment seeking overweight peers Thus, it may be important to further explore the role of social skills and social support in a sample of non treatment seeking children. There are some limitations with the current study that deserve mention. First, there were a significant number of children ( N = 82 ) that were not included in the analyses, mostly as a result of attrition or insufficient data. This may have resulted in a selection bias such that the remai ning participants reported high levels of social functioning and physical activity. In turn, reduced variability among the examined constructs may have limited power to detect significant relationships. Also, the cross sectional design of the current study precludes evidence for directionality among social skills and physical activity. Finally, this study used a measure of peer victimization and social support that is not specific to weight status or physical activity. Utilizing the weight teasing subscale from the Perceptions of Teasing Scale (Thompson, Cattarin, Fowler, & Fisher) or the Teasing/Marginalization subscale of the Sizing Me Up questionnaire (Zeller & Modi, 2009) may have yielded greater report of peer victimization. Likewise, questions that ass ess peer support in the context of participation in physical activity may have been more appropriate to use in a study examining social functioning and health behaviors. Moreover, the method used to assess physical activity presents as a potential key lim itation of this study. Although accelerometry based activity monitors have become the most widely used objective assessment of physical activity among youth, many challenges concerning the measurement accuracy of these devices remain. More
41 specifically, th e sporadic and intermittent levels of physical activity in children (Freedson, Pober, & Janz, 2005) and variability due to growth and maturation (Wickel, Eisenmann, & Welk, 2007) make the assessment of physical activity in youth particularl y complex. First there is no identified criterion for how much wear time is necessary to define a valid day of measurement. Several studies have used at least 10 hours of daily wear time in youth ( Ekelund et al., 2001; Macfarlane, Lee, Ho, Chan K., & Chan D., 2006; Riddoch et al., 2004 ); however, it is difficult to generalize this criteria to all studies, given that many children are not required to wear the device for 24 hours a day. While the current study follows guidelines by encouraging children to wear the acce lerometer during waking and sleeping hours, additional issues of practicality arise, as many children may have removed the accelerometer during sleep or periods of competitive vigorous activity to reduce discomfort. This may have limited comparability betw een participants, especially since physical activity was expre ssed as a daily average value. Although analyzing minutes of wear time during sleep would likely not be feasible in a sample this size, it may be useful to instead determine average daily minute s of physical activity relative to daily minutes of wear time. Furthermore, a lthough children were told to maintain normal level s of physical activity while wearing the accelerometers, and had not yet received any educational material on the topic of phys ical activity at this point in treatment, it is possible that children participated in more than usual amounts of physical activity during this time. In one study, accele rometer counts we re 3% higher during the first day of measureme nt than subsequent days in 11 year old children (Mattocks et al., 2008). However, because
42 this issue wa s not apparent on other days, it may be advisable to just disregard the first day of measu rement (Corder et al., 2008). Keeping these limitations in mind, future studies should continue to investigate the association between these variables using a longitudinal design. Moreover, u tilizing meditational models to explore relationships among thes e variables may also be useful, as other factors, including internalizing behaviors or social support, may better explain the association between social skills and physical activity. There is already some research to suggest that these relationships may ex ist, with a few studies reporting that depressive symptoms are associated with social skills deficits and problems with peers (Deater Deckard, 2001; Hay, Payne, & Chadwick, 2004; Masten, 2005; Segrin, 2000). Also, Dierk and colleagues (2006) proposed a mod el that suggests social skills enhance Researchers are encouraged to also explore the relationship between social skills and quality of life in overweight youth, especially since overweight children have been shown to experience more deficits in physical and social quality of life than non overweight children (Williams, Wake, Hesketh, Maher, & Waters, 2005). There has been research to suggest that social support and social skills, rather than BMI, are associated with subjective well being in obese adults (Dierk et. al, 2006 ), which highlights the importance of social functioning and social relationships in enlisting support for and adopting a healthy lifestyle. Finally, dieting and food intake modifications are also critical elements in the treatment of childhood overweight (Latzer et al., 2009). Thus, future research should also examine the relationship between social skills and unhealthy eating behaviors.
43 Considering that this sam ple of youth reported adequate social skills and peer social support, they may be more integrated into various social networks, and thus receive Findings from this study offer a new perspective on social func tioning in overweight youth, with a sample of treatment seeking overweight children reporting social skills that are comparable to those of non overweight same age peers. Also, it is promising that, on average, this sample reported high levels of peer supp ort and low levels of peer victimization. While social skills do not appear to be related to youth involvement in physical activity among treatment seeking youth, it is necessary to examine this relationship among children who experience more victimization and social marginalization within the peer environment. When making recommendations for diet and physical activity, i t is imperative that clinicians and health care professionals become aware of the difficulties encountered by overweight youth in the soci al environment, keeping in mind that negative peer interactions may limit motivation to engage in healthy behavior s.
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54 BIOGRAPHICAL SKETCH Shana Schuman is a second year graduate student in the Clinical and Health Psychology Program at the University of Florida. She obtained a Bachelor of Science degree in psychology at the University of Florida in 2008 and completed an honors thesis on parent predictors of child and adolescent body dissatisfaction Shana has also worked as a research assistant on studies involving children with chronic pulmonary conditio ns, including asthma and cystic fibrosis. She is currently serving as a group leader for a family based weight management program for children living in rural counties in Florida. She is also managing a study examining psychosocial functioning in adolesc ents with Inflammatory Bowel Disease.