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ENGAGING THE FAMILY TO PROMOTE CHILD PHYSICAL ACTIVITY

Pratt, Keeley J. Ph.D., LMFT; Cotto, Jennifer M.S.; Goodway, Jacqueline Ph.D.

doi: 10.1249/FIT.0000000000000325
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Apply It! • Practitioners will review the evidence on family-based physical activity interventions targeting caregivers and youth.

• Practitioners will observe the combination of health behavior and family systems theories to inform family-based physical activity interventions.

• Practitioners will receive recommendations for family-based physical activity assessments targeting physical activity in the family and the caregiver-child relationship dynamic.

• Practitioners will obtain relevant examples that address caregiver and youth physical activity support, barriers, rules, and the caregiver-child family dynamic.

Keeley J. Pratt, Ph.D., LMFT,is an assistant professor in Human Development and Family Science and the Couple and Family Therapy Specialization in the Department of Human Sciences at The Ohio State University. Over the past decade, Dr. Pratt has worked with pediatric obesity treatment centers, residential healthy lifestyle camps, adult outpatient weight management, and bariatric surgery programs as a family therapist and researcher. Dr. Pratt uses mixed methods to focus on the following areas of research: 1) family dynamics and relationships that contribute to obesity or are modifiable in treatment; 2) family-based, multidisciplinary weight management treatment models; 3) tailoring obesity treatment for racial/ethnic minority and underserved and insured families; and 4) expanding mental and behavioral health training to include weight bias and systemic work with families with overweight and obesity.

Jennifer Cotto, M.S.,is a doctoral student completing the Health and Exercise Behavior Specialization in the Kinesiology Program in the Department of Human Sciences at The Ohio State University. Her research interests include physical activity engagement, family dynamics, and obesity treatment and prevention. More specifically, she is interested in using family system principles to investigate how family dynamics and relationships affect the physical activity engagement and weight status of family members.

Jacqueline Goodway, Ph.D.,is a professor in the Physical Education Program in the Kinesiology Program Area, in the Department of Human Science at The Ohio State University. Her research agenda focuses on issues associated with the promotion of motor skill development and physical activity in young children who are at risk and/or economically disadvantaged. She has implemented numerous motor skill interventions demonstrating significant improvements in fundamental motor skill development for the children involved as well as improvements in psychosocial factors associated with physical activity. Dr. Goodway also has found that contextual variables such as family demographics, type and number of risk factors, and community and cultural factors influence motor development.

Disclosure:The authors declare no conflict of interest and do not have any financial disclosures.

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OBESITY PREVENTION AND FAMILY-BASED PHYSICAL ACTIVITY

Because of their shared environment and genetics, family members often have similar health behaviors, leading them to have similar weight statuses. In fact, youth (children and adolescents) with one caregiver (e.g., guardian, parent) with obesity have 2 to 3 times greater odds of being obese than those without a caregiver with obesity (16). Caregivers’ influence on youth physical activity has been well established (4), and interventions that help caregivers adopt healthy dietary and physical activity behaviors also enhance outcomes for their youth (6). Caregivers influence youth physical activity through direct involvement in their activities, serving as role models, providing encouragement for physical activity, engaging youth, and providing transportation to organized physical activity events (i.e., sports) (4). Furthermore, caregiver support is the best predictor of youths’ long-term participation in organized physical activities.

Practitioners working with youth to change their health behaviors, including physical activity, and ultimately reduce their weight status are recommended to provide family-based care (1). Family-based care involves both a targeted caregiver and a youth as the focus of interventions and can extend beyond the caregiver-youth dyad to include additional family members (regardless of biological relatedness). Family-based interventions are effective at reducing youths’ weight status and adopting new diet and physical activity behavioral changes (2). Family-based physical activity interventions promote long-term changes in physical activity among youth, and increases in caregivers’ own physical activity contributed to increases in youths’ physical activity (15). In addition, family-based physical activity interventions have been shown to improve family relationships (11).

Despite the benefit of family-based physical activity interventions, several barriers exist to their implementation. Barriers that have been identified by caregivers include lack of time and childcare, caregiver fatigue, having youth of different ages/developmental stages with different interests, weather conditions, lack of access to facilities where youth can be physically active, and lack of transportation and money to support physical activities (14). An additional barrier noted by caregivers is the relationship dynamic between caregivers and youth, including communication and challenging custody or coparenting arrangements (10). For families with challenging caregiver-youth dynamics, it is unlikely that newly adopted physical activity behaviors will be sustained without addressing the dynamics that potentially influence the broader family routines, rules, and communication around health behaviors.

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COMBINING HEALTH BEHAVIOR AND FAMILY SYSTEMS THEORIES

To engage caregivers and youth in family-based physical activity interventions, both health behavior and family systems theories are needed to address the caregiver-youth dynamic and both caregiver and youth’s behaviors. The combination of family systems theory (FST) and social cognitive theory (SCT) can be used as a framework to assess caregiver and youth physical activity behaviors and the caregiver-youth dynamic (Figure). Caregiver-youth relationship dynamics intercept multiple areas where caregivers and youth are both social and cohabitate, thus an influential “social system” for caregiver and youth behavior change. FST describes families as bidirectional systems where reciprocal interactions occur simultaneously between both caregivers and youth (4,6). According to FST, families strive to maintain homeostasis, or a normal way of functioning, and will attempt to return to their normal way of functioning despite outside influences (5). When a caregiver adopts new physical activity behaviors or habits, the youth may either change their behavior to be like their caregiver or begin exhibiting maladaptive behaviors. SCT posits that individuals learn new behaviors by observing other’s actions and the subsequent consequences of their actions (7). Youth who observe the adoption of new physical activity behaviors by their caregiver may be more likely to adopt said behaviors and sustain these changes over time if their caregiver does. Overall, the combination of FST and SCT describes the shared environment in which caregivers and youth coexist and find models and support for their health behaviors (SCT) in their family relationships, where the health behaviors of caregivers and youth bidirectionally influence one another and ultimately their overall relationship (FST). Examples of FST and SCT assessments and methods for engaging families are provided hereinafter.

Figure. C

Figure. C

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CAREGIVER AND YOUTH PHYSICAL ACTIVITY ASSESSMENT

To assess youth and caregiver relationship dynamics and how the dynamic associates with physical activity behaviors in the family, brief assessments of both physical activity support and barriers in the family and family functioning can be used. Specific to physical activity support and barriers, the Parental Rules and Restrictions Scale (9) assesses caregivers’ rules and restrictions around the youth’s physical activity, including support, indoor rules, general and environmental barriers (including safety) for physical activity, and computer restriction. The Social Support for Physical Activity survey (13) evaluates different aspects of support for physical activity including caregiver encouragement, praise, transportation for physical activity, participation with the youth, and watching the youth participate in sports or activities. Both of these brief assessments administered before intervening with the family can provide the practitioner valuable information about how to tailor his/her counseling based on families’ existing barriers, caregiver support, and existing rules for physical activity. For example, if a lack of caregiver support for physical activity is indicated, practitioners can counsel caregivers about what kind of support they have provided in the past and what it would take for their level of support to increase, and they could provide relevant resources to increase their perception of the support they could provide for their youths’ physical activity.

The Family Assessment Device (FAD) is the most common measure used to assess family functioning, with seven scales with clinical cutoff scores to indicate healthy or impaired family functioning (12). The FAD scales include problem-solving, communication, roles, affective responsiveness, affective involvement, behavior control, and general functioning. For providers interested in a brief measure of overall family functioning, the general functioning scale (11 items) is an acceptable proxy for overall family functioning to determine if families are above or below the cutoff score(s) for healthy functioning (8).

Families with healthy functioning have appropriate boundaries between caregivers and youth and have caregivers that take responsibility for providing healthy meal and snack options and opportunities for physical activity. Families without healthy functioning may present with the youth having the “power” in the family, or as chaotic or disorganized. In these cases, interventions may need to focus on supporting the caregiver(s) to assume more structure with their parenting and how to extend that structure to physical activity behaviors.

Families with healthy functioning have appropriate boundaries between caregivers and youth and have caregivers that take responsibility for providing healthy meal and snack options and opportunities for physical activity. Families without healthy functioning may present with the youth having the “power” in the family, or as chaotic or disorganized.

In addition to assessments about family functioning and family support, barriers, and rules for physical activity, inquiring about relevant household information can help practitioners determine who should be involved with the youth’s physical activity intervention. For example, asking where the youth spends most of their time, including shared custody or child care arrangements, allows providers to tailor their intervention to family members and the households where youth spend their time. Inquiring about the actual family structure also can provide relevant information about who lives in the home(s) with the youth including siblings, grandparents, single- or two-parent families, or other family or nonfamily members living in the home. Practitioners also should ensure that physical activity or exercise is not used as a reward or punishment but can be done regardless of the youth’s behavior so that healthy routines can be developed.

Finally, assessing caregiver and youth strengths in relation to their family and physical activity can help practitioners to be strengths based in their counseling. For example, to assess family strengths, practitioners can ask the following:

  • “What do you like most about your family (or youth, caregiver)?”
  • “What is something you have done where you had to work together to complete it?”
  • “How have you provided support or encouragement to each other in the past?”

To assess physical activity strengths for caregivers and youth, practitioners can ask the following:

  • “What activities do you think are easier for you or ones that you are particularly good at?”
  • “Can you think of a goal you have set before and how you achieved it?”
  • “What activities do you enjoy doing with your family (or youth, caregiver)?”

One benefit of asking about general family strengths, referred to in the first set of bullets, is that the practitioner can apply the noted family strengths to physical activity‐specific goals. For example, if a youth states that his/her caregiver helps him/her with his/her math homework, the practitioner can look for ways that the caregiver is providing oversight and supervision with the math homework and apply this to physical activity engagement with their youth. Assessing family functioning, family support, rules and barriers for physical activity, and family strengths can help providers determine if caregivers and youth may benefit from interventions targeting both family dynamics and physical activity or primarily physical activity.

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FAMILY-BASED PHYSICAL ACTIVITY INTERVENTION

Caregivers and youth with impaired family functioning, limited support for physical activity, and noted barriers may benefit from interventions that target both the relationship dynamic between the caregiver and youth relevant to physical activity and behavioral components that promote physical activity. The Table contains behavioral and family systems information that practitioners can use when conducting family-based physical activity interventions. The left column outlines traditional behavioral physical activity components, and the right column details family systems topics around physical activity for practitioners to consider for families with impaired family functioning and noted challenges and barriers. For example, if families note impairments in the caregiver-youth relationship dynamic, practitioners can work with families to improve support, problem-solve noted barriers, improve communication in the family about physical activity, make implicit and explicit rules clear in and outside of the home for physical activity, participate as a family in physical activities, and increase the strengths that families have relevant to physical activity. These areas address the dynamic between the caregiver and youth while remaining relevant to physical activity behaviors. The more standard behavioral areas of physical activity intervention, which are detailed in the other articles of this special issue, include self-monitoring, goal setting, problem-solving, behavioral contracting, and relapse prevention. For the purposes of this article, examples of family systems physical activity topics to include in consultations with caregivers and youth are described hereinafter. Family strengths and barriers are addressed previously and for the sake of space are not expanded on in this article.

TABLE Fa

TABLE Fa

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Family Support for Physical Activity

Practitioners working with caregivers to enhance support for their youths’ physical activity may benefit by first asking about how they provide support to their youth in other ways (i.e., school). Based on the detail caregivers provide about other ways they offer support, practitioners can explore how these types of support can be applied to physical activity. For example, if a caregiver supports his/her youth for an hour every day with their homework, practitioners can work to see how they could spend time together participating in physical activities as well.

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Family Rules for Physical Activity

Practitioners working with families who may have impaired family functioning also may have rules that are not established or are unclear around physical activity. These families often benefit from exploring the explicit and implicit rules around physical activity in the home and outside the home. For example, an explicit well-understood rule may be that children cannot be outside without an adult because of safety concerns. Whereas, an implicit rule may be that a caregiver will be active with his/her child after the dinner dishes are done. Making the implicit rules about physical activity in the family and household more explicit allows for more realistic goal setting for physical activity.

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Family Communication About Physical Activity

Families with low support and impaired family functioning likely have difficulty communicating effectively. This can be especially problematic for caregivers and children when setting goals and working toward goals. Practitioners can work with caregivers and youth to set goals and to communicate how they would like to support and encourage each other toward those goals. One way to do this is to ask family members to think about ways they can remind each other, without nagging, about keeping up with their physical activity goals. For example, a caregiver may commit to remind his/her adolescent to walk after dinner and volunteer to go with him/her. If the adolescent indicates he/she does not want to walk today (for whatever reason), the caregiver cannot remind him/her again. Discussing these kinds of negotiations up front can help address barriers before they start.

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Family Participation in Physical Activity

Finally, practitioners should address how family members have participated in physical activities together in the past and how family participation has changed over time. If a family had little participation together in physical activities, practitioners should work with the family to set small, feasible goals to set the family up for success early on. An example would be going for a 10-minute walk after dinner three times per week and slowly increasing the amount of time spent walking. Practitioners also should work to understand the schedules and demands placed on each family member to be sensitive to the degree of involvement they can have in family physical activities. For example, practitioners should be sensitive of caregivers who are working third shift and have different time demands.

If a family had little participation together in physical activities, practitioners should work with the family to set small, feasible goals to set the family up for success early on. An example would be going for a 10-minute walk after dinner three times per week and slowly increasing the amount of time spent walking.

Based on the success of caregivers and youth over time, practitioners can readminister any of the aforementioned assessments to determine if changes occurred to physical activity behaviors and family support and functioning and what may need to be a new focus for intervention. If families struggle to achieve their goals or to adopt new physical activity behaviors, practitioners can look to involve additional support in and outside the family, involve existing support in different ways, and negotiate new goals within the family.

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SUMMARY

Caregivers play an important role in how active youth are and what kinds of physical activity options youth have. Family-based physical activity interventions promote fun, physical activity for youth, caregivers, and family members. However, barriers can exist for families to participate in physical activity, and furthermore, to enjoy their time together. Using social contagion theory, FST, and SCT, practitioners working with caregivers and youth to promote physical activity can assess both physical activity‐related strengths, barriers, support, and resources (via the Parental Rules and Restrictions Scale) and general family strengths and overall family relationships (via the FAD) to determine how supportive the family environment is to adopt new physical activity behaviors. Furthermore, family-based physical activity assessments and interventions can identify strengths, barriers, and dynamics both specific to physical activity and generally to set the family up for long-term sustainable change.

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BRIDGING THE GAP

Practitioners working with youth to change their physical activity behaviors are recommended to provide family-based care by targeting both caregivers and youth in physical activity interventions. Using both behavioral and family theories, this article provides practitioners with methods for family-based physical activity assessment and caregiver and youth intervention engagement to promote physical activity in families.

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Keywords:

Family; Parenting; Parent-Child; Physical Activity Intervention; Obesity

© 2017 American College of Sports Medicine.