Role of Care Neglect and Supervisory Neglect in Childhood Obesity Article Critique

Role of Care Neglect and Supervisory Neglect in Childhood Obesity Article Critique

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Summary: The summary should be between 1 and 2 paragraphs. This should briefly explain the authors’ purpose(s), method, and results (main findings in your own words. No numbers.) Keep the summary informative, but concise (less than a page). Role of Care Neglect and Supervisory Neglect in Childhood Obesity Article Critique

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Critique: You should critique the articles based on the following criteria. Be sure to completely and concisely address each point. Remember this should be a critical assessment or the study (objective). DO NOT INCLUDE YOUR OPINION. Paraphrase , no direct quotes.Role of Care Neglect and Supervisory Neglect in Childhood Obesity Article Critique

1. Purpose/Research Question: Determine the authors’ purpose of the research and state it in your own words. Comment on how clearly this was presented in the article.
2. Method: Comment on how appropriate the method used was for addressing the purpose. State if the method was employed effectively.Role of Care Neglect and Supervisory Neglect in Childhood Obesity Article Critique
3. Evidence of Support: Examine the method and results of the article and determine if they helped the authors effectively address the purpose presented. Also discuss the strengths and weaknesses of the evidence and the study as a whole.
4. Real World Application: After reading the discussion section summarize any real world implications the authors suggest. Also give your own suggestions for the real world application of the study and its’ findings. Role of Care Neglect and Supervisory Neglect in Childhood Obesity Article Critique
5. Recommendations: Determine who might benefit from the article, what the benefit may be, and the importance of the benefit. Here you may summarize your subjective judgments of the work and suggestions on how to improve or extend the work.Role of Care Neglect and Supervisory Neglect in Childhood Obesity Article Critique

child obesity neglect

The Role of Care Neglect and Supervisory Neglect in Childhood
Obesity in a Disadvantaged Sample
John F. Knutson, PHD, Sarah M. Taber, MA, Amanda J. Murray, MA, Nizete-Ly Valles, BS and
Gina Koeppl, PHD
The University of Iowa
Objective Assess the roles of care neglect and supervisory neglect, and the moderating influence of child age
on childhood obesity. Study Design Child BMI, parental care neglect, and supervisory neglect were assessed
in an ethnically diverse sample of 571 young children from two Midwestern States. Hierarchical linear regression
was used to assess the influence of both forms of neglect and the moderating role of age. Results Fifteen
percent of the children were overweight and 16.3% were obese. Care neglect significantly correlated with child
BMI for younger but not older children, while supervisory neglect significantly correlated with child BMI for
older but not younger children. Conclusions The impact of two types of neglect on obesity varied across
age, highlighting the importance of differentiating between types of neglectful parenting when addressing
the high rate of childhood obesity in disadvantaged children.Role of Care Neglect and Supervisory Neglect in Childhood Obesity Article Critique
Key words age moderation; body mass index; care neglect; disadvantaged children; supervisory neglect.
Prevalence rates of childhood obesity have evidenced
a marked increase in the United States and globally
(Cornette, 2008). Although obesity itself can be problematic
for children’s health, it also has been implicated as a
risk factor in children and adolescents for problems that
include stigmatization, impaired health, low self-esteem,
poor quality of life, psychological distress, and suicidal
ideation (Adams & Bukowski, 2008; Cornette, 2008;
Hebebrand & Herpertz-Dahlmann, 2009). Though genetic
and hormonal conditions can predispose some children to
obesity, factors such as diet and physical activity play a
substantial role in determining children’s weight. Recent
increases in the rates of childhood obesity are taken as
evidence of the impact of environmental factors on childhood
weight gain (Hebebrand & Hinney, 2009). Although
there has been considerable discussion of potential environmental
contributors to childhood obesity, most of
the possible contributors have not yet been thoroughly
researched. Among the possible factors that could contribute
to childhood obesity are deficient parenting and maltreatment
(c.f. Gilbert et al., 2009).Role of Care Neglect and Supervisory Neglect in Childhood Obesity Article Critique
A number of lines of evidence have implicated neglectful
parenting as a factor in childhood obesity. An early
study by Christoffel and Forsyth (1989) detailed the life
circumstances of 12 severely obese pediatric patients and
noted that their family environments were characterized by
disorganization, separation of mother and child, displacement
of child care, parental denial of the child’s weight
problem, and inconsistent medical follow-up, all facets
of care that are often subsumed under considerations of
neglect in the child maltreatment literature (c.f. Dubowitz,
2006; Knutson & Schartz, 1997; Trocme´, 1996). Although
describing those family attributes as probable contributors
to obesity, the Christoffel & Forsyth (1989) study did not
have any comparison conditions. Recent studies provide
evidence that neglect and sexual abuse, but not physical or
emotional abuse, are associated with an increased risk of
obesity in childhood and young adulthood (Noll, Zeller,
Trickett, & Putnam, 2007; Whitaker, Phillips, Orzol &
Burdette, 2007). Although the Whitaker et al. (2007)
study was based on a large sample, the index of neglect
was limited to five items from a self-report scale. Other
evidence consistent with the hypothesized link between
neglectful parenting and obesity comes from retrospective
studies of childhood experiences among adults presenting
with obesity (Williamson, Thompson, Anda, Deitz, &
All correspondence concerning this article should be addressed to John F. Knutson, E11 Seashore Hall, Iowa City, IA
52242, USA. E-mail: john-knutson@uiowa.edu
Journal of Pediatric Psychology 35(5) pp. 523–532, 2010
doi:10.1093/jpepsy/jsp115
Advance Access publication December 8, 2009
Journal of Pediatric Psychology vol. 35 no. 5 The Author 2009. Published by Oxford University Press on behalf of the Society of Pediatric Psychology.
All rights reserved. For permissions, please e-mail: journals.permissions@oxfordjournals.org
Felitti, 2002), and a prospective study from Denmark
in which teacher and school nurse ratings of childhood
neglect predicted obesity in young adulthood (Lissau &
Sorensen, 1994). This latter finding is similar to a recent
prospective study in which sexual abuse was implicated in
young adult obesity, but not obesity earlier in development
(Noll et al., 2007). If neglect were related to the development
of obesity, the high prevalence rate of neglect [Office
of Human Development Services (OHDS), 1981, 1988;
Sedlak & Broadhurst, 1996; U.S. Department of Health
and Human Services, Administration on Children, Youth,
and Families, 2001, 2002] would suggest it could be a
major factor to consider in efforts to address childhood
obesity.Role of Care Neglect and Supervisory Neglect in Childhood Obesity Article Critique
Neglect is commonly described as a circumstance
wherein parental inaction or inattention results in harm
to a child, or a circumstance where the basic needs of a
child are not met (Polansky, Hally & Polansky, 1975).
Because so many different events can be subsumed
under such a broad definition, researchers have offered
various taxonomies of neglect (c.f. Giovannoni, 1985;
Hegar & Yungman, 1989; Sedlak & Broadhurst, 1996;
Trocme´, 1996) that could be used to clarify exactly how
circumstances of neglect are associated with distinct child
outcomes. Recently, Knutson, DeGarmo, & Reid (2004)
and Knutson, DeGarmo, Koeppl, & Reid (2005) argued
for a theoretical model that distinguished between care
neglect and supervisory neglect and provided empirical
evidence that these two forms of neglect contributed,
as independent factors, to the development of young children’s
aggression. In those studies, care neglect included
such conditions as poor hygiene, exposure to household
environmental hazards, and inadequate health care.
Supervisory neglect was conceptualized as parental lack
of awareness of child activities, personal preferences, and
the child’s engagement in risky or deviant behaviors. Either
form of neglect could contribute to childhood obesity,
albeit through somewhat different processes.
Parents evidencing supervisory neglect may contribute
to their child’s obesity by failing to adequately monitor
their child’s physical activities and ingestive behaviors
and by failing to exert an influence on both activity and
eating habits. Parents may also contribute to their child’s
obesity via care neglect by failing to ensure the provision
of appropriate nutrition and health care. Because the
Whitaker et al. (2007) study implicated neglectful parenting
in the obesity of preschool children, and other studies
seem to suggest the impact could be delayed in school age
children (Lissau & Sorensen, 1994), it is possible that the
impact of both forms of neglect would be a function of
the age of a child, especially when age differences reflect
important differences in development and extrafamilial
influences. Thus, in examining the putative links between
care neglect or supervisory neglect and childhood obesity,
it is important to consider the moderating influence of
a child’s age, particularly when samples span periods of
significant developmental change.
The present study was designed to examine the impact
of Care Neglect and Supervisory Neglect on childhood
obesity. Because both neglect and obesity are exacerbated
by poverty and limited access to resources [NIS; Office
of Human Development Services (OHDS), 1981, 1988;
Sedlak & Broadhurst, 1996; Swinburn, 2009] the present
study assessed the relation between the two forms of
neglect and obesity within a sample of children living
in circumstances of disadvantage. Additionally, with
sexual abuse implicated in the development of obesity
(Noll et al., 2007) the present study was conducted with
a sample in which children known to have been sexually
abused were excluded from the sample. It was hypothesized
that younger children (preschool and kindergarten)
may be more susceptible to care neglect. In contrast, parental
supervision may become a more significant factor as
children develop, engage in more contexts outside the
home, and begin to evidence greater degrees of independence.
Thus, it was hypothesized that the early school-aged
children (first grade and up) in the sample would be more
susceptible to supervisory neglect.Role of Care Neglect and Supervisory Neglect in Childhood Obesity Article Critique
Methods
Subjects
The 571 participating socially disadvantaged children, and
their parent(s), had been enrolled in two ongoing studies
of parenting and children’s social development. The children
were recruited from two counties in southeastern
Iowa (n¼389) and a single county in north central
Wisconsin (n¼182). The resulting sample was diverse
with respect to degree of urbanization as well as ethnic
and racial composition. The children in the sample were
described by their parent as 61.6% White (non-Hispanic),
19.4% Black, and 19% as members of other racial or
ethnic groups (Latino/a, Multi-ethnic/Multiracial, Native
American, Asian/Pacific Islander). Ages ranged from
3 years 7 months to 9 years 6 months (M¼6 years
3 months, SD¼17.3 months), and the sample of children
was 50.6% male. Mothers were self-described as 69.9%
White (non-Hispanic), 19.8% Black, and 10.2% as members
of other racial or ethnic groups (Latina, Multi-ethnic/
Multiracial, Native American, Asian/Pacific Islander).
Although disadvantaged, mothers evidenced a range of
occupations and educational attainment.
524 Knutson, Taber, Murray, Valles, and Koeppl
Families were eligible to participate in the two longitudinal
studies if they received any form of service from
their state or county social service agency during the three
months preceding enrollment. Children who had been
identified as neglected or physically abused were eligible
to participate in both projects, although those who were in
an out-of-home placement, who were known to have been
sexually abused, or who were actively enrolled in intensive
interventions related to parenting were not eligible. The
second project was also designed to enroll families in
which domestic violence had occurred. Because exposure
to domestic violence constitutes neglectful parenting in
Iowa and Wisconsin, families enrolled in the first project
could also have been characterized by domestic violence.
Thus, participants from both projects were drawn from
essentially the same high-risk population. Comparisons
between the samples did not identify any differences
with respect to demographic variables or any core variables
in this report.Role of Care Neglect and Supervisory Neglect in Childhood Obesity Article Critique
The informed consent and enrollment in both projects
occurred during an in-home interview with the parent;
all other variables were assessed in subsequent laboratory
sessions. Mothers were compensated $50 per session and
children could select a toy valued at $10 or $10 cash. The
projects were conducted under the aegis of The University
of Iowa Institutional Review Board (IRB) and Certificates of
Confidentiality. The protocol explicitly precluded informing
the social service agencies whether families elected to
enroll in the project. Thus, there were no social-service
inducements to participate. Because of the complexity of
the recruitment process it is impossible to determine unequivocally
the number of eligible subjects who were actually
contacted (i.e., read the recruitment letters). Indirect
evidence derived from telephone contacts, returned letters,
and focus groups with the targeted population suggests
that 50% of eligible families were actually contacted
and 50% of contacted families scheduled an initial
home visit. Less than 1% of those scheduling an in-home
recruitment visit declined to participate. Some of the subjects
participating in the current study were described in
Knutson et al. (2005), DeGarmo, Reid, & Knutson,
(2006), Knutson, Lawrence, Taber, Bank, & DeGarmo
(2009), and Valles & Knutson, (2008).
Procedure
Initial face-to-face contact with the mother occurred during
an 90-min appointment in the home, where informed
consent was obtained. Immediately following the informed
consent process a structured interview regarding the
circumstances of the child’s life, family background,
and living conditions was conducted. This structured interview
was based, in part, on a modification of the Home
Observation for Measurement of the Environment (HOME:
Caldwell & Bradley, 1978; Leventhal, Selner-O’Hagan,
Brooks-Gunn, Bingehheimer & Earls, 2004), and, in
part, on the framework that emerged from the recommendations
of the Research Sub-Committee of the Interagency
Task Force on Child Abuse and Neglect (Sternberg et al.,
2004). The interview included questions related to
injury prevention (c.f. Peterson, Ewigman, & Kivlahan,
1993) and home safety (Tymchuk, Lang, Dolyniuk,
Berney-Ficklin & Spitz, 1999). Because the interview
occurred in participants’ homes, it was possible to directly
assess circumstances of neglect, including sleeping
arrangements, cleanliness, plumbing, personal hygiene of
family members, and any hazards threatening children in
the household. During the first laboratory session, typically
scheduled within 10–15 days of the in-home visit, the
child’s height was measured within 0.5 inches and
clothed-weight was obtained. The mother and child also
participated in a structured parent–child interaction, and
each completed a number of standardized psychological
instruments, most of which do not pertain to the current
report. More detailed descriptions of the protocols and
procedures can be found in Knutson et al. (2005),
DeGarmo et al. (2006), Shay & Knutson (2008), and
Valles & Knutson (2008).Role of Care Neglect and Supervisory Neglect in Childhood Obesity Article Critique
Measures

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Home Environment Questionnaire
The Home Environment Questionnaire (HEQ; Laing &
Sines 1982; Sines, Clarke, & Lauer, 1984) is a psychometrically
reliable true/false questionnaire that uses objectively
phrased items to obtain information about the child’s
environment from the child’s parent. Developed using
the rational–statistical approach (c.f. Loevinger, 1956),
the HEQ has eight empirically derived scales measuring
dimensions of a child’s environment that are theoretically
relevant for the expression of deviant and nondeviant child
behaviors (Murray & Sines, 1996). The Achievement
scale measures family conditions that model or provide
support for achievement on the part of the child. The
Socioeconomic Status scale is comprised of items that
refer to activities and attitudes related to academic and
intellectual pursuits, as well as participation in community
affairs. These two scales have been effectively combined
with maternal occupational and educational attainment
in an index of family social disadvantage (Knutson et al.,
2005) within economically disadvantaged samples.
Care Neglect and Supervisory Neglect 525
Mothers’ T-scores on the HEQ Achievement subscale
ranged from 23 to 72 (M¼46.1, SD¼9), and the
Socioeconomic Status subscale scores ranged from 29 to
86 (M¼51.8, SD¼9.6).
Care Neglect
The multisource measure of care neglect (Knutson et al.,
2005) consisted of a 56-item summative index that was
derived, in part, from the in-home interview and reflected
both parent report and objective observer ratings of care
neglect (e.g., child does not have a toothbrush, has not
had a routine medical or dental examination in over
12 months), and household environmental conditions
that would occasion social (household is overly crowded;
inadequate illumination; inadequate furniture) and physical
risks to a child (unsafe stairs; inadequate plumbing;
animal feces present; accessible pharmaceuticals).
Proximal circumstances outside the home that could occasion
direct risk to the child that were observed during the
home visit (e.g., broken glass, drug paraphernalia) were
also included in the Care Neglect Index. Items were all
scored in a direction to indicate neglect and summed.
The obtained total Neglect Index scores ranged from 4 to
24 (M¼11.8, SD¼3.6).
Supervisory Neglect
As noted by Dishion and McMahon (1998) awareness of
child activities is a critical component of parental supervision.
Thus, for the young children of the present study, the
construct of supervision was measured by parental awareness
of child activities reflected in congruence between
parent report and child report. Based on the work of
Knutson et al. (2005) two concordance scores were derived
to measure effective supervisory skills of the parent. The
first index was the correspondence between child report
and parent report on the Children’s Reinforcement Survey
Schedule (RSS; Clement & Richard, 1976). The RSS,
administered by interview, asks children to identify the
people with whom they spend the most time, their favorite
foods, toys they use most often, activities in which they
frequently engage, and the places they spend the most
time. They are also asked to identify toys they don’t have
but would like, places they would like to spend more time,
additional activities in which they would like to participate,
and people with whom they would like to spend more
time. The parent completes a paper and pencil RSS form
which contains the same categories as the child version.
Hall (1986) used the effective agreement for occurrence
statistic between the child report and the parent report
on the RSS as a single index of supervision in a study of
the development of externalizing disorders in young
children. In the present study, based on the work of Hall
(1986), the RSS concordance score (M¼.37, SD¼.09)
was used as an index of the parents’ awareness of the
more routine aspects of their child’s life.
As a second indicator of supervision, more related to
deviant behavior or developmentally risky acts, the parent
and the child independently completed The Children’s
Experience and Excitement Scale (CEES: Selner, 1992;
Selner & Knutson, 1990). The CEES consists of 44
slides depicting children engaging in a range of activities.
To minimize sex role responding there is one form for
boys, with male actors, and another form for girls, with
female actors. In an interview format, child subjects are
asked whether they have ever engaged in the activity
depicted in the slide. If they had not engaged in the activity,
they were asked whether they had the opportunity to
do so. Parents complete the CEES in a self-report format by
indicating whether their child has ever engaged in the
pictured activity and whether they would allow their
child to engage in the pictured activity. Concordance
between child and parent reports of experienced activities
across slides provides the second indicator of supervision.
Complementing the RSS-based measure of routine activities,
the CEES concordance measure provides an indicator
of the parent’s awareness of their child engaging in frankly
deviant acts or developmentally inappropriate activities.
The index ranged from 12 to 42 agreements (M¼31.8,
SD¼4.3).Role of Care Neglect and Supervisory Neglect in Childhood Obesity Article Critique
Parent–child concordance scores from the CEES
and RSS were significantly, albeit modestly, correlated
(r¼0.17, p<.01). Because Knutson et al. (2005) and
the DeGarmo et al. (2006) successfully used a
factor-analytical combination of the CEES and RSS concordance
scores and documented the utility of this
approach to studying supervision, the two scores were
combined using principal components factor analysis to
create an overall Supervisory Neglect score.
Results
Childhood Obesity
Body mass index (BMI) scores and age-based BMI percentile
scores were derived using the Centers for Disease
Control and Prevention (CDC) SAS program for calculating
2000 Growth Chart scores (Ogden et al., 2002). Children’s
BMI scores ranged from 7.75 to 37 (M¼16.7, SD¼3.06).
Based on the CDC growth charts and recommendations for
the identification of outliers, two children were identified
as extremely low BMI outliers and were excluded from the
analyses. This resulted in BMI scores ranging from 11.6
to 37 (M¼16.7, SD¼3.03; n¼569). Age adjusted
526 Knutson, Taber, Murray, Valles, and Koeppl
percentile scores for BMI were also calculated. Based on
the recommendations of the Expert Committee on
Pediatric Obesity (Barlow and the Expert Committee,
2007), children in the age-based 84–95th percentile can
be classified as overweight and at risk for obesity, while
those >95th percentile are classified as obese. Based on
these classifications, 14.9% of the sample was within the
at-risk range, while 16.3% would be considered obese.
These findings are consistent with previous research
demonstrating that rates of obesity can surpass rates of
risk for obesity in disadvantaged samples (Ogden et al.,
2002; Lacar, Soto, & Riley, 2000). The rate of obesity in
the present sample was approximately three times the CDC
Growth Chart norms and the combined rate of obese and
overweight children was approximately twice that which
could be expected from the Growth Chart norms.
Bivariate correlations between the BMI, demographic variables,
and the indices of neglect were low (<10), not statistically
significant, but consistent with the hypothesized
moderated processes.
Care Neglect
The link between the Care Neglect Index and BMI percentile
scores was assessed in a hierarchical linear regression
designed to determine the moderating role of child age.
Although the sample was entirely economically disadvantaged,
because social status has been strongly linked to
both neglect (Sedlak & Broadhurst, 1996) and childhood
obesity (Swinburn, 2009), a derived social status factor
score (principal components extraction) comprised of the
two HEQ subscales and the mother’s education and occupational
attainment was calculated. Education was scaled
to range from 1 ‘‘never reached high school’’ to 8 ‘‘graduate/
professional degree’’ and occupation was scaled
to range from 1 ‘‘unskilled laborer’’ to 7 ‘‘professional.’’
This social status factor score was then entered into the
regression model as a control variable. In addition, all main
effects were centered prior to conducting the regression
analysis with the interaction terms. Results of this regression
analysis are summarized in Table I. Social status was
not significantly related to child BMI percentile. The
two-way interaction of Age and Care Neglect emerged as
significant in the initial regression and remained significant
in the tested reduced model that included only the two
main effects and the interaction (N¼567). Follow-up tests
of the interaction were conducted to determine the nature
of significant moderation effects following recommendations
of Cohen and Cohen (1983) and Holmbeck
(2002). Regression slopes depicting the association
between child BMI and Care Neglect Index scores were
examined at levels of the moderator (Age) both 1 SD
above and below the mean. Care Neglect was significantly
associated with BMI for younger children (standardized
b¼.17, p<.01, t¼2.8) but not older children (standardized
b¼.03, p¼.65, t¼.45).Role of Care Neglect and Supervisory Neglect in Childhood Obesity Article Critique
Supervisory Neglect
The link between Supervisory Neglect and BMI percentile
scores was assessed using an identical analytic method,
controlling for social status with the derived factor score.
The results of the regression are summarized in Table II.
Based on the nonsignificant results of the initial regression
Table II. Summary of Regression Analysis Examining Age as a
Moderator of the Relation between Supervisory Neglect and
Child BMI Percentile (N¼504)
Variable B SE B b t
Step 1
Social Status 1.78 1.9 .04 .93
Step 2
Child’s Age .14 .09 .07 1.54
Step 3
Supervisory Neglect 2.32 3.02 .04 .77
Step 4
AgeSocial Status .10 .12 .04 .84
AgeSupervisory Neglect .27 .17 .07 1.58
Social Status
Supervisory Neglect
1.76 3.60 .02 .49
Step 5
AgeSocial Status
Supervisory Neglect
.04 .20 .01 .19
R2¼.00 for Step 1; R2¼.00 for Step 2; R2¼.00 for Step 3; R2¼.01 for
Step 4; Final R2¼.02.
Table I. Summary of Regression Analysis Examining Age as
a Moderator of the Relation between Care Neglect and Child
BMI Percentile (N¼514)
Variable B SE B b t
Step 1
Social Status .92 1.84 .02 .50
Step 2
Child’s Age .12 .09 .06 1.38
Step 3
Care Neglect .49 .42 .05 1.17
Step 4
AgeSocial Status .03 .11 .01 .26
AgeCare Neglect .06 .03 .10 2.22*
Social StatusCare Neglect .90 .51 .08 1.78
Step 5
AgeSocial Status
Care Neglect
.05 .03 .07 1.60
R2¼.00 for Step 1; R2¼.00 for Step 2; R2¼.00 for Step 3;
R2¼.01 for Step 4; Final R2¼.03.
*p<.05.
Care Neglect and Supervisory Neglect 527
using the Supervisory Neglect factor score, an alternate
analysis of supervisory neglect was considered. This decision
was based, in part, on the modest correlation between
the CEES and RSS congruence scores and, in part, on the
leptokurtic and positively skewed congruence scores
between parent-child reports on the CEES, resulting in a
relatively restricted range of CEES congruence scores and a
limited contribution to the overall Supervisory Neglect
score. Additionally, although this combined Supervision
score was effectively used in testing models pertaining to
children’s aggression (Knutson et al., 2005), the more deviant
behaviors represented in the CEES might not pertain
to supervision relevant to ingestion and general physical
activity. Thus, two alternative regression analyses were conducted
to examine a possible relation between different
age-moderated scores of supervisory neglect and child
BMI: one using the congruence scores derived from the
RSS and one using the congruence scores derived from
the CEES (Tables III and IV). As expected, based on the
distributional characteristics of the sample, the CEES congruence
scores were not related to BMI percentile scores.
However, in the parallel regression analysis, the two-way
interaction between Age and the RSS emerged as statistically
significant and remained significant in the tested
reduced model (N¼549) including only the two main
effects and the interaction. Follow-up tests examining the
nature of the significant interaction demonstrated that
supervision, as measured by RSS congruence scores, was
significantly related to BMI percentile scores for older children
(standardized b¼.13, p¼.03, t¼2.2) but not
younger children (standardized b¼.06, p¼.33, t¼.97).
Discussion
The present study was designed to evaluate the putative
link between neglectful parenting and childhood obesity.
Moderation analyses yielded support for the hypothesis
that care neglect was significantly associated with
age-based BMI percentile scores in younger but not older
children. Although these findings are limited by their correlational
nature, they do suggest that failing to adequately
provide for a child’s basic needs may have more detrimental
effects in younger (i.e., preschoolers and kindergarteners)
rather than older children (i.e., 6- to-9-year-olds), at
least with respect to concurrent obesity. In the current
study, the Care Neglect Index was based on a
multi-method/multisource approach and included both
circumstances within direct parental control (e.g., child
has no toothbrush) and environmental conditions
(unsafe stairs, broken glass) that might be the responsibility
of another party. As noted by Dubowitz (2006), neglect
must be defined in terms of events that impinge on the
child rather than being limited by who bears the responsibility
for those events. Thus, a directly assessed
broad-based index of neglect was related to concurrent
obesity in younger children, all of whom were from circumstances
of disadvantage. The lack of an association
between care neglect and obesity in older children is consistent
with the findings of Lissau and Sorensen (1994).
Specifically, they failed to demonstrate a relation between
childhood obesity and neglect in a sample of 9- to
10-year-olds, although childhood neglect did correlate
with obesity in young adulthood. Because the present
study is limited by correlational data and concurrent indices
of obesity and neglect, prospective longitudinal studies
Table III. Summary of Regression Analysis Examining Age as a
Moderator of the Relation between RSS Supervision Score and
Child BMI Percentile (N¼508)Role of Care Neglect and Supervisory Neglect in Childhood Obesity Article Critique
Variable B SE B b t
Step 1
Social Status 1.78 1.85 .04 .96
Step 2
Child’s Age .12 .09 .07 1.44
Step 3
RSS 12.86 16.28 .04 .79
Step 4
AgeSocial Status .07 .11 .03 .61
AgeRSS 2.09 .95 .10 2.20*
Social StatusRSS 13.43 20.72 .03 .65
Step 5
AgeSocial StatusRSS .34 1.09 .02 .32
R2¼.00 for Step 1; R2¼.00 for Step 2; R2¼.00 for Step 3;
R2¼.01 for Step 4; Final R2¼.02.
*p<.05.
Table IV. Summary of Regression Analysis Examining Age as a
Moderator of the Relation between CEES Supervision Score and
Child BMI Percentile (N¼509)
Variable B SE B b t
St

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ep 1

Social Status 1.82 1.87 .05 .97
Step 2
Child’s Age .11 .09 .06 1.24
Step 3
CEES .07 .359 .01 .21
Step 4
AgeSocial Status .11 .11 .05 1.0
AgeCEES .00 .02 .01 .15
Social StatusCEES .22 .42 .03 .52
Step 5
AgeSocial StatusCEES .02 .03 .04 .78
R2¼.00 for Step 1; R2¼.00 for Step 2; R2¼.00 for Step 3;
R2¼.00 for Step 4; Final R2¼.01.
528 Knutson, Taber, Murray, Valles, and Koeppl
are needed to clarify the link between care neglect and
obesity, and those studies should represent a broad age
range of children who might be differentially vulnerable
to specific aspects of parenting.Role of Care Neglect and Supervisory Neglect in Childhood Obesity Article Critique
The finding that care neglect is associated with elevated
BMI scores in young children can be seen as consistent
with the case-study material provided by Christoffel
and Forsyth (1989), and the study by Whitaker et al.
(2007). However, the Whitaker et al. study used the
5-item Neglect Scale from Parent–Child Conflict Tactics
Scale (Straus, Hamby, Finkelhor, Moore & Runyan,
1998) to assess neglectful parenting; those few items
assess components of care neglect, supervisory neglect,
and even parental substance abuse. Thus, the specific parental
deficiencies that may contribute to childhood obesity
are not clearly delineated and it is impossible to determine
whether the current care neglect findings are truly consistent
with the Whitaker et al. findings, or whether the
Whitaker et al. findings might represent other features of
neglect. It is also important to note that emerging evidence
has linked child sexual abuse to later obesity. To the extent
that sexual abuse covaries with other forms of child maltreatment
(c.f. Sullivan & Knutson, 1998, 2000), it is important
to attempt to parse the links between various forms
of child maltreatment and poor child outcomes. In the
present study, children known to have been sexually
abused were not eligible for participation. Although children
whose sexual abuse was unknown at the time of
enrollment may have participated, the base rate of sexual
abuse is known to be low in the present study. In the
Whitaker et al. study, child sexual abuse was not measured
in the birth cohort that was used, and it is unknown
whether co-occurring sexual abuse could be a factor in
that research.
To examine whether supervisory neglect was associated
with childhood obesity, the first analysis used a
supervision factor score that had been used in earlier
work (DeGarmo et al., 2006; Knutson et al., 2005).
Although the overall Supervisory Neglect factor score did
not correlate with child BMI percentiles, the parent–child
concordance score based on the RSS was related to concurrent
BMI in the age-moderation analyses. The RSS concordance
score reflects parental awareness of the more
routine aspects of their child’s life and incorporates information
relevant to ingestive behavior. Because awareness
of child activities, persons with whom they associate,
and places they spend time is a prerequisite for effective
supervision, the RSS concordance index should tap
domains of child behavior that are related to ingestion
and exercise. Thus, although this analysis was post hoc,
the age-moderated findings are consistent with theoretical
and empirical considerations of the role of supervision
(Dishion & McMahon, 1998) and Hall’s (1986) use of
the RSS congruence score. Furthermore, given that poor
supervision was significantly related to concurrent obesity
in older but not younger children, the findings suggest that
parental awareness of their young school-aged child’s daily
activities may be particularly important as the child becomes
increasingly independent. Because previous studies
have not isolated the unique contribution of supervisory
neglect to obesity, a replication of this moderated supervision
effect would be appropriate. Additionally prospective
studies of supervision, and experimental interventions designed
to alter parental supervision, should be conducted
to determine whether a focus on supervision would be
an effective strategy for influencing the BMI trajectory of
school-aged children. Such experimental studies, conducted
in the context of a therapeutic intervention,
would make it possible to avoid the limitations of correlational
designs.Role of Care Neglect and Supervisory Neglect in Childhood Obesity Article Critique
Given the correlational nature of the data, it is impossible
to identify a specific mechanism whereby neglectful
parenting or poor supervision could confer risk for childhood
obesity. A number of viable candidates can be identified.
Obtaining mothers’ BMI scores was not part of the
research protocol, but informal observations suggested an
association, albeit not perfect, between maternal obesity
and child obesity. While it is tempting to invoke notions
of heritability, it is also the case that poor attention to
healthy habits, exercise, and excessive ingestion would
confer risk for obesity to both adults and children in a
household. The link between child sexual abuse and later
obesity has been hypothesized to be a consequence of
stress experienced by the child, resulting in a dysregulation
of the hypothalamic–pituitary–adrenal (HPA) axis and
associated neuro-hormonal problems that result in metabolic
dysfunction, as well as ingestive problems (c.f. Noll
et al., 2007). Dysregulation of the HPA axis could also be a
consequence of being reared in a neglectful home. The
notion that neglectful parenting could result in an
increased allostatic load (c.f. McEwen, 2003) that predisposes
a child to react adversely to normal circumstances of
stress is another mechanism whereby early neglect could
confer risk for obesity. Although the neglect assessed in
this study is not likely to be an acute traumatic stressor,
living under the conditions of the more neglecting households
is likely to be associated with chronic stress and
increased allostatic load. Of course, both neglectful parenting
and childhood obesity could reflect the operation of an
unmeasured third variable. Although an attempt was made
to control for the obvious third variable of social disadvantage,
the approach used does not exhaust the range of
Care Neglect and Supervisory Neglect 529
adverse environmental events that could confer risk to
both neglect and childhood obesity.
The results of this study do have implications for the
health care of disadvantaged children. Within this disadvantaged
sample, the obesity rates are alarming and underscore
the critical need to develop efforts to mitigate obesity
in youth living in poverty. Although the base rate of obesity
is high in this sample, the data are not unlike those from
other studies with disadvantaged children (Ogden et al.,
2002; Lacar et al., 2000). Of course, not all children in the
sample were overweight or obese. Moreover, the index of
social disadvantage based on household attributes, maternal
education, and maternal occupation did not correlate
with obesity. Thus, poverty per se is not the sole contributor
to obesity and, within a disadvantaged sample, some
degree of social advantage (i.e., educational attainment;
occupational attainment) does not seem to reduce risk
for childhood obesity. Because the amount of variance
accounted for by the parenting indices was modest, the
findings indicate that childhood obesity is a multidetermined
problem that is not likely to yield to simple
parenting solutions. The findings do underscore the need
of practitioners to focus some efforts on circumstances of
care neglect for preschool and kindergarten children, and
consider efforts to enhance parental supervision of children
in the early elementary school years. Importantly,
the association between BMI percentile scores and indices
of parenting also suggest that BMI can serve as a potential
marker of care neglect in young children and poorer supervision
in older children.Role of Care Neglect and Supervisory Neglect in Childhood Obesity Article Critique
Acknowledgment
The statistical consultation by Jacob J. Oleson, and the
facilitation of the research by Trisha Barto, Marc Baty,
Barry Bennett, Wayne McCracken, Mindy Norwood,
Jeff Regula, Mark Schmidt, and Cheryl Whitney (Iowa
Department of Human Services), Paul Spencer (Oneida
County Department of Social Services), and the assistance
of Ashley Anderson, Robin Barry, Lisa Bauer, Allyson Bone,
Beth Boyer, Kristy DePalma, Aubra Hoffman, Esther
Hoffman, Kathryn Holman, Kyla Kinnick, Robert
Latzman, Mary McCarren, Katie Meyer, Bethany Murphy,
Laureen Ann Rapier, Eunyoe Ro, and Nicole Shay is gratefully
acknowledged.
Funding
This research was supported in part by grant RO1
MH 61731 funded by National Institute of Mental
Health and Agency for Children, Youth, and Families
(to J. F. K., PI); and in part by grant R01 HD-46789
funded by Eunice Kennedy Shriver National Institute of
Child Health and Human Development (to J. F. K., PI).
Conflicts of interest: None declared.
Received March 5, 2009; revisions received October 23,
2009; accepted October 29, 2009
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