Original Article

Associations Between Adult Attachment Style, Emotion Regulation, and Preschool Children’s Food Consumption Kelly K. Bost, PhD,* Angela R. Wiley, PhD,* Barbara Fiese, PhD,* Amber Hammons, PhD,† Brent McBride, PhD*; The STRONG KIDS Team ABSTRACT: Objective: The goal of this study was to test 3 serial mediation models of how caregiver adult attachment style influences children’s food consumption through its influence on emotion regulation. Three mediators that have been shown to increase the risk for pediatric obesity and that are likely to be influenced by negative emotion regulation strategies in everyday family interactions were chosen: (1) caregiver feeding practices (2) family mealtime routines, and (3) child television (TV) viewing. Method: A total of 497 primary caregivers of 2.5- to 3.5-year-old children reported on their own attachment style, typical responses to their children’s negative affect, feeding styles, mealtime and TV viewing routines, and their children’s consumption of healthful and unhealthful foods. Results: Insecure mothers were more likely to use punishing or dismissing responses to their children’s negative affect, and negative emotion regulation predicted the increased use of emotion-related feeding styles and fewer mealtime routines. These variables, in turn, were found to predict children’s unhealthful food consumption, documenting serial mediational influences. With respect to TV viewing, caregiver insecurity influenced child food consumption indirectly through its direct effect on child TV viewing. Conclusion: Taken together, these data suggest that insecure attachment may put parents at a risk for using negative emotion regulation strategies in response to their children’s distress, which may also have important implications for the interpersonal environment surrounding food and the development of children’s early eating behaviors. (J Dev Behav Pediatr 35:50–61, 2014) Index terms: pediatric obesity, adult attachment style, emotion regulation.

P

ediatric obesity experts have called for developmental and family models to discover specific processes in the emergence of unhealthful and healthful eating patterns.1,2 This may be especially important during the preschool years because one quarter of 2- to 5-year olds in the United States are overweight or obese3 and weight increases between 2 and 5 years predict adult overweight status.4 Studies of parents’ contributions to children’s eating behavior and pediatric obesity have focused primarily on food access, restriction, and preferences. This extensive work has revealed robust associations between parental and child food preference and consumption behaviors.5 Demanding and restrictive parental feeding styles have also been From the *Department of Human and Community Development, University of Illinois, Urbana, IL; †Department of Child, Family and Consumer Sciences, Fresno State University, Fresno, CA. Received February 2013; accepted September 2013. Disclosure: This research was funded, in part, by grants from the Illinois Council for Agriculture Research to Kristin Harrison (PI) and the University of Illinois Health and Wellness Initiative. This project was also supported by the USDA National Institute of Food and Agriculture, Hatch projects to K. Bost (project ILLU-793-343), to A. Wiley (project ILLU-793-321-0205791), and to B. Fiese (project ILLU-793-328). The authors declare no conflict of interest. The members of the STRONG KIDS Team are given at the end of the article. Address for reprints: Kelly K. Bost, PhD, Department of Human and Community Development, University of Illinois, 2008 Doris Christopher Hall, 904 West Nevada Street, Urbana, IL 61801; e-mail: [email protected]. Copyright Ó 2013 Lippincott Williams & Wilkins

50 | www.jdbp.org

shown to predict child overweight/obesity and children’s unhealthful food consumption.6 However, intervention efforts focused on feeding goals that alter children’s energy intake and expenditure balance have been largely ineffective or untested,7 and researchers are requesting a broader assessment of how parenting behaviors and interpersonal environments may shape children’s early eating behaviors. Effective clinical practice can be informed, in particular, by the exploration of mechanisms that connect aspects of parenting, children’s eating behavior, and childhood obesity. One promising focus is how the parent-child relationship may affect obesity-related outcomes by influencing children’s emotion regulation.8 Adopting an attachment theory framework,9 Anderson et al10 have reported longitudinal data from the Study of Early Child Care and Youth Development, linking the quality of early maternal-child relationships (at 15, 24, and 36 months) to adolescent obesity at 15 years of age (see also previous findings of Anderson and Whitaker11). The authors propose that one underlying mechanism accounting for these associations is the well-documented impact of attachment relationships on capacities to regulate negative affect and stress responses.12,13 Stress responses, in turn, have been associated with obesity and metabolic syndrome,14 and emotion dysregulation has been linked to higher sweet/salty foods intake and increases in children’s body mass index (BMI).15,16 Journal of Developmental & Behavioral Pediatrics

Although these data are provocative, there are no documented associations between caregiver or child attachment, emotion regulation, and children’s eating behavior, despite research linking parental unresponsiveness to child hunger cues with later feeding difficulties and difficulty self-regulating energy intake.17 This study extended previous findings by documenting the associations between parent attachment and children’s consumption of unhealthful foods. We tested 3 serial mediation models, examining how caregivers’ insecure attachment may influence children’s food consumption by influencing emotion regulation. We selected 3 (second) mediators known to increase the risk for pediatric obesity and that may be influenced by ineffective emotion regulation strategies in everyday family interactions: (1) caregiver feeding practices, (2) family mealtime routines, and (3) child television (TV) viewing. Figure 1 depicts the conceptual model, and the literature for the hypothesized associations is presented below.

Attachment and Emotion Regulation The attachment system is an innate regulatory mechanism that promotes children’s proximity to caregivers in times of distress, uncertainty, or threat.9 Secure attachment relationships, with available and responsive caregivers, provide children with a “secure base” to explore the environment, a safe haven in times of distress or uncertainty, and a source of joy under ordinary conditions.12 In contrast, insecure attachment relationships often evoke feelings of anxiety, uncertainty, and potentially threat in close relationships.9 Affective interchanges are central in the development of attachment relationships, and qualitatively distinct emotional response patterns emerge from attachment histories, largely independent from inherited differences in reactivity and regulation.12,18 Secure individuals have enduring emotional security and open and flexible expressions of emotion. Insecure individuals suppress

negative affect and/or have overly intense emotional responses due to histories of either angry/rejecting caregiver responses to normative bids for help or contact, or having to escalate normative bids for contact because of inconsistent responsiveness of the attachment figure.19 The attachment relationship is, in part, a dyadic context for regulating overwhelming emotional stress and embracing positive experiences. If stressreducing components of the parent-child relationship are regularly absent, then neurohormonal systems can become stress sensitive and impair children’s regulatory capacities.20 By adulthood, attachment histories become internalized as potent social schemata within personality and relationship development. Studies document adult attachment style differences in coping with stress,21 and experiencing and regulating affect.13,22,23 Insecure adults with dysregulated emotional responding are especially at risk for ineffective parenting12 behaviors surrounding their children’s sleep/wake cycles,24 stress reactivity, and escalation25—all implicated in pediatric obesity.

Emotion Regulation and Eating Emotional overeating is associated with controlling caregiver feeding practices (CFPs), including giving children preferred foods in response to distress or negative mood states. In an experimental induction of negative mood, preschoolers whose mothers reported using food to regulate children’s distress consumed significantly more palatable foods in the absence of hunger than did those whose mothers rarely used emotion CFPs.26 Emotional overeating also increases and remains considerably stable between 4 and 10 years of age.27 Caregiver attachment and associated emotion regulation strategies might influence children’s eating behavior by impacting feeding styles of the parent. Model 1 tested associations between caregiver insecure attachment and children’s unhealthful food consumption with emotion

Figure 1. Conceptual serial mediation model of the relations between insecure attachment, emotion regulation, and children’s unhealthful food consumption. Model 1 tests caregiver feeding practices as the second mediator; Model 2 tests mealtime routine as the second mediator; and Model 3 tests child television viewing as the second mediator. Vol. 35, No. 1, January 2014

© 2013 Lippincott Williams & Wilkins

51

regulation as Mediator 1 and negative parent feeding strategies as Mediator 2. Based on theory (insecure attachment is linked to emotion dysregulation, and emotion dysregulation and overeating are associated), we hypothesized that caregiver insecure attachment would be significantly associated with caregivers’ negative (e.g., punitive, dismissing) emotion regulation strategies in response to children’s distress. These emotion regulation strategies were hypothesized to significantly influence CFPs which, in turn, were hypothesized to predict children’s unhealthful food consumption (Fig. 1).

Family Mealtime Routines Caregivers’ ineffective stress responses may impact children’s food consumption through family activities beyond feeding styles. Attachment relationships are coconstructed through everyday interactions (e.g., feeding, playing, sleep routines). Over time, these interaction patterns can promote predictability and self-regulation.28 Reviewing 50 years of research, Fiese et al29 reported that family routines are associated with parenting skills and child competence. Engagement in family routines has also been shown to lower the likelihood of obesity in preschool-aged children.30 One routine that consistently predicts obesity-related outcomes is family mealtime routines (FMR). Sharing a family meal 4 or more times/week is associated with healthy child outcomes, including greater consumption of fruit and vegetables, reduced consumption of high-calorie foods,31 and a reduced risk for childhood obesity.32 Based on these findings, Model 2 examined hypothesized associations between caregiver insecure attachment and children’s food consumption through its effects on emotion regulation (first mediator) and FMR (second mediator; Fig. 1).

Child Television Viewing Television viewing is linked to unhealthy eating33 and excess adiposity in preschoolers.34 Especially relevant to this study are findings linking parent stress and child TV viewing. Emotionally distressed parents allow their children more TV time than those without distress.35 Insecure caregivers, who are more likely to have ineffective emotion regulation strategies, may use TV to manage or avoid stress during routine interactions with children. Model 3 tested whether child TV viewing operates as a second mediator in the relations between caregiver insecure attachment and children’s unhealthful food consumption (Fig. 1). It was hypothesized that insecure caregivers would have more difficulty managing children’s negative affect and would allow more TV viewing time. Child TV viewing, in turn, was hypothesized to predict children’s food consumption.

METHOD Participants The 497 families were recruited from 32 child care centers located in 3 counties in central Illinois. Fifty-one 52 Adult Attachment and Children’s Food Consumption

percent had children (48.9% girls) in Child and Adult Care Food Programs–qualified centers, 14.9% had children in Head Start Programs, and 33% of the parents were participants in the Women, Infants, and Children supplemental nutrition program. Primary caregivers were on average 32.45 years of age, 94% were biological parents, and 90% were female. Approximately 70% of the primary caregivers were White, 18.2% African-American, 8% Asian, and 3.8% were Latino. With the exception of participants who self-identified as Latino, these percentages reflect US Census data for Illinois (78%, 14.8%, 4.8%) and the nation (78.1%, 13.1%, 5.0%) for White, African-American, and Asian population categories, respectively.36 Approximately 11% reported a high school education or less, 32.1% had some college or technical training; 26.3% had college degrees, and 27.9% had postgraduate degrees. Nearly half (47.8%) reported annual household income of ,$40,000, and 29% of the sample reported annual household income of ,$24,000. Overall, the sample is representative of families who have preschool-aged children in full-time child care in Central Illinois.

Procedure This study is part of a transdisciplinary research and education program created to document factors in family and child care settings that predict healthy eating practices and physical activity levels across the preschool period. For the panel survey, primary caregivers of preschool-aged children between 2.5 and 3.5 years of age were sent consent forms through their child care centers. Participants could complete an online or paper survey, then receive a $50.00 gift card. This study was approved by the University of Illinois Institutional Review Board for the protection of human subjects.

Measures Caregiver Attachment Style Adult attachment style was assessed with the widely used, 30-item Relationship Scales Questionnaire (RSQ).37 On a 5-point Likert-type scale ranging from 1 (not at all like me) to 5 (very much like me), participants rate the extent to which each statement best describes their characteristic style in close relationships. The RSQ is a standard self-report measure of global adult attachment styles, and it has been shown to predict emotional response patterns in close relationships21,22 and parental responsiveness to their children’s distress.38 Recent longitudinal data show that RSQ-assessed adult attachment styles can be predicted from early caregiving environments.39 The RSQ scores in this sample are also significantly and negatively related to child security scores (based on home observations of parent-child interaction) in a subsample (n 5 75) of participating families. Because adult attachment researchers recommend deriving dimensional scores of attachment-related anxiety and avoidance,40 a principal components analysis (varimax rotation) was implemented. Results revealed Journal of Developmental & Behavioral Pediatrics

a 3-factor solution accounting for 48% of the variance. Factor 1 included 12 items (a 5 .88) reflecting attachment-related anxiety/fear (e.g., “I worry that I will be hurt if I allow myself to become too close to others”). Factor 2 included 10 items (a 5 .82) reflecting dismissing/avoidant attachment (e.g., “I am comfortable without close emotional relationships”). The 7-item Factor 3 (a 5 .81) reflected attachment security (e.g., “I find it easy to get emotionally close to others”). Three composite scores, created by averaging items for each factor solution, were labeled (1) insecure anxious/fearful, (2) insecure dismissing/avoidant, and (3) secure. Bivariate correlations revealed substantial correlations in the 2 insecure scores (r 5 .62; p , .001); these were averaged to create a total insecure attachment score. Caregiver Responses to Their Children’s Negative Emotion The Coping with Children’s Negative Emotions Scale (Fabes et al41) assesses parents’ perceptions about their reactivity to children’s negative affect. Given descriptions of 11 common situations (e.g., if the child loses a favorite toy and becomes upset), parents rate typical responses on a 7-point Likert-type scale ranging from 1 (very unlikely) to 7 (very likely). Six subscales (12 items each) are derived, reflecting specific types of emotion regulation strategies: Distress reactions (a 5 .60; e.g., “feel upset and uncomfortable myself”); punitive reactions (a 5 .72; e.g., “tell my child to straighten up/calm down or we’ll go home right away”); expressive encouragement (a 5 .91; e.g., “encourage my child to talk about his/her fears”); emotion-focused reactions (a 5 .83; e.g., “comfort my child and try to get him/her to forget about the accident”); problem-focused reactions (a 5 .84; e.g., “help my child think of something to do so that he/she can get to sleep”); and minimization reactions (a 5 .76; e.g., “tell my child to quit overreacting and being a baby”). Because bivariate correlations revealed substantial associations between the distress, punitive, and minimization subscales (r 5 .32 to .65; all p , .001) and between expressive encouragement, emotion-focused reactions, and problem-focused reaction subscales (r 5 .54 to .80; all p , .001), composite scores were created to reflect total positive emotion regulation (average of expressive encouragement, emotion-focused reactions, and problem focused reactions subscales) and negative emotion regulation strategies (average of distress, punitive, and minimization subscales). Caregiver Feeding Styles Parent feeding styles were assessed using the Comprehensive Feeding Practices Questionnaire (CFPQ)42. The CFPQ (49 items; 12 subscales) asks parents to rate how often they use specific feeding practices on a 5-point Likert-type scale ranging from 1 (never) to 5 (always), and it has demonstrated adequate validity and reliability with American parents of 2- to 8-year olds.42 Based on bivariate correlations between subscales, 2 composite scores were created. The first reflected emotion-related, Vol. 35, No. 1, January 2014

pressuring feeding styles that have been shown to predict obesity and was computed as an average of the food as reward (a 5 .70; e.g., “I offer my child his/her favorite foods in exchange for good behavior”), emotion regulation (a 5 .72; e.g., “Do you give this child something to eat or drink if he/she is upset even if you think he/she is not hungry?”), and pressure to eat (a 5 .69; e.g., “My child should always eat all of the food on his/her plate”) subscales. The second composite score, reflecting healthy feeding styles, was computed as the average of the teaching about nutrition (a 5 .66; e.g., “I discuss with my child the nutritional value of foods”), modeling (a 5 .87; e.g., “I model healthy eating for my child by eating healthy foods myself”), involvement (a 5 .75; e.g., “I involve my child in family meals”), balance and variety (a 5 .74; e.g., “I encourage my child to try new foods), and environment (a 5 .66; e.g., “Most of the food I keep in the house is healthy”) subscales of the CFPQ. Family Mealtime Routine The 7-item Family Ritual Questionnaire43 scale assesses frequency and planning of family mealtimes and communication during mealtimes (e.g., “During mealtimes, family members help and support one another”). Caregivers rated each item on a 5-point Likert-type scale ranging from 1 (not at all true) to 5 (very true). A principal components analysis (varimax rotation) revealed that all items loaded on 1 factor (factor loadings ranging from .55 to .80) and accounted for 46% of the variance (a 5 .58). Composite family mealtime routines (FMR) scores were created by averaging the 7 items. Child Television Viewing Child television (TV) viewing was measured by an index of total minutes spent watching “on a typical weekday” and “on a typical weekend day” as reported by caregivers.44 On an 8-point scale, parents reported the number of minutes (ranging from 0 minutes to 5 or more hours) of TV before, during, and after child care on a typical weekday and in the morning, after lunch, and after dinner on a typical weekend day. Total TV viewing scores were computed by summing across weekday and weekend items. Parents reported that their children watched, on average, 1.5 hours of television a day. Child Food Consumption Questions regarding children’s food consumption were taken from the Early Childhood Longitudinal Study-B (ECLS-B) parent interview child health section.45 The ECLS-B was drawn from a national representative sample of 14,000 children and has been used successfully to study child health outcomes. Parents were asked to report, over the past 7 days, on their children’s consumption of a variety of foods/drinks on a 6-point scale ranging from 0 (none) to 6 (4 times a day). Composite scores were created that included an average of the “fresh fruit” and “vegetables” items (healthful) and an average of the “sugary drinks,” “salty snacks,” “candy and sweets,” and “fast food” items (unhealthful). Primary caregivers reported that on average, their children consumed fresh fruit and vegetables twice a day and © 2013 Lippincott Williams & Wilkins

53

unhealthful foods/beverages 4 to 6 times in the past week (Table 1). Caregiver Depression/Anxiety Because our primary focus was on attachment-related insecurity, we included a standard measure of depression and anxiety for statistical control. The depression and anxiety scales of the 21-item Depression Anxiety Stress Scales (DASS46) were used. The DASS is a widely used and validated measure in clinical and nonclinical samples. Caregivers were asked to indicate, over the past week, the degree to which each item applied to them on a 3-point Likert-type scale from 0 (did not apply to me at all) to 3 (applied to me very much; most of the time). The depression subscale (a 5 .84) consists of 7 items (e.g., “I couldn’t seem to experience any positive feeling at all”) and the anxiety subscale (a 5 .52) also includes 7 items (e.g., “I experienced trembling”). Means and standard deviations are provided in Table 1.

Multiple Imputations Missing data were imputed using the fully conditional specification (FCS) method in SPSS Statistics for Windows, Version 21.0 (IBM Corp., Armonk, NY). The FCS method iteratively fits regression equations in which each variable in the imputation model is successively treated as an outcome variable and regressed on all other variables. Imputed values are predicted from the set of regressions and added random error components.47 Researchers now recognize the value of using multiple imputation methods in analyzing data sets with missing data over traditional methods that are more likely to produce biased estimates and reduce statistical power.47 A total of 5 data sets were imputed

using all model variables. Imputed values were pooled and used in subsequent analyses. Table 1 depicts descriptive data for both original and imputed data.

RESULTS Preliminary Analyses Preliminary analyses examined the relations between model variables and standard demographic variables and also statistical controls relevant to our hypotheses (i.e., maternal body mass index [BMI], maternal age, and maternal depression and anxiety). Only 1 significant gender difference emerged: parents of girls (mean 5 17.09; standard deviation [SD] 5 2.35) were significantly more likely than parents of boys (mean 5 16.57; SD 5 2.44) to report using positive emotion regulation strategies (F1,403 5 4.71; p , .05). As such, child gender was used as a statistical control in relevant analyses. Because children’s unhealthful food consumption was found to differ significantly according to race (F3,441 5 31.97; p , .001) and education level (F4, 456 5 13.32; p , .001); both were used as statistical controls in subsequent analyses.

Bivariate Correlations Between Covariates and Model Variables Table 2 shows correlations between additional (continuous) covariates and model variables for pooled imputed data. Caregiver age was significantly and negatively associated with child television (TV) viewing, unhealthful food consumption, and Comprehensive Feeding Practices Questionnaire (CFPQ) emotion regulation/pressure feeding

Table 1. Means and Standard Deviations of Variables in the Model for Original and Imputed Data Total number of Original Data

Mean Original Data

Caregiver age

453

32.45

6.68

32.47

Child age (mo)

496

39.04

8.19

39.03

Caregiver body mass index

468

27.35

6.50

27.40

Caregiver depression

464

1.33

0.44

1.33

Standard Deviation of Pooled Mean Original Data Imputed Data

Caregiver anxiety

467

1.26

0.37

1.26

Anxious/avoidant attachment

449

2.33

0.64

2.31

Caregiver negative emotion regulation responses to child’s distress

381

6.90

1.73

6.91

Caregiver positive emotion regulation responses to child’s distress

464

16.83

2.42

16.75

Mealtime routine

478

2.78

0.756

2.79

Total television viewing

445

16.81

6.56

16.97

Total child consumption of unhealthy food (salty snacks, fast food, sugary drinks)

459

2.07

0.76

2.06

Total child consumption of fruits and vegetables

481

4.24

1.13

4.23

Caregiver feeding style—teaching and modeling

458

3.67

0.58

3.67

Caregiver feeding style—emotion regulation/ pressure

458

2.16

0.45

2.16

54 Adult Attachment and Children’s Food Consumption

Journal of Developmental & Behavioral Pediatrics

style, and it was significantly and positively associated with FMR. Parents of relatively older children were significantly less likely to use positive emotion regulation strategies and reported that their children watched significantly more TV and consumed significantly more unhealthful foods (and less healthful foods) than parents of younger children. Caregiver BMI correlated significantly with child TV viewing and unhealthful food consumption (positively) and CFPQ teaching/modeling and CFPQ emotion regulation/pressure (negatively). More depressed parents were significantly more likely to use negative emotion regulation strategies and emotion regulation caregiver feeding practices (CFPs), were less likely to

have regular family mealtime routines (FMRs), and reported that their children consumed less healthful foods than less depressed mothers. Similarly, more anxious caregivers were more likely to use negative emotion regulation strategies and reported that their children watched more TV and ate more unhealthful foods than less anxious caregivers. Because of these significant associations, caregiver age, BMI, DASS-depression, DASS-anxiety, and child age were all used as covariates in model testing.

Bivariate Correlations for Hypothesized Relations Bivariate associations were examined to explore the relations between caregiver attachment, emotion

Table 2. Correlations Among Variables in the Model for Pooled Imputed Data 1

2

3

4

5

6

7

Caregiver age

—

—

—

—

—

—

—

Child age

.00

—

—

—

—

—

—

.04

.08

—

—

—

—

—

Caregiver depression

2.02

.07

.19***

—

—

—

—

Caregiver anxiety

2.09

.10*

.20***

.52***

—

—

—

Anxious/avoidant attachment

2.06

.03

.08

.36***

.33***

—

—

Caregiver negative emotion regulation responses to child’s distress

2.03

.10*

2.03

.18**

.20**

.26***

—

Caregiver positive emotion regulation responses to child’s distress

.00

2.15*

2.08

2.05

.01

2.04

2.10*

Caregiver body mass index

Mealtime routine

.15**

Total television viewing

2.15**

.22***

.25***

.20***

Total child consumption of unhealthy food (salty snacks, fast food, sugary drinks)

2.14**

.18***

.15**

.08

2.02

2.02

2.22***

2.08

2.12**

2.14**

2.21***

.22***

.14**

.13**

.16**

.10

Total child consumption of fruits and vegetables

.05

2.11*

2.07

2.14**

Caregiver feeding style—teaching and modeling

.00

.12

2.09

2.02

.09

2.18**

.11*

.08

Caregiver feeding style—emotion regulation/pressure 2.18**

2.13**

2.06

2.13**

.07

2.04

2.12**

.11*

.32***

8

9

10

11

12

13

14

Caregiver age

—

—

—

—

—

—

—

Child age

—

—

—

—

—

—

—

Caregiver body mass index

—

—

—

—

—

—

—

Caregiver depression

—

—

—

—

—

—

—

Caregiver anxiety

—

—

—

—

—

—

—

Anxious/avoidant attachment

—

—

—

—

—

—

—

Caregiver negative emotion regulation responses to child’s distress

—

—

—

—

—

—

—

Caregiver positive emotion regulation responses to child’s distress

—

—

—

—

—

—

—

—

—

—

—

—

—

Total television viewing

2.04

2.23***

—

—

—

—

—

Total child consumption of unhealthy food (salty snacks, fast food, sugary drinks)

2.06

2.22***

.35***

—

—

—

—

2.19***

2.07

—

—

—

2.17**

2.25***

.31***

—

—

.16**

.20***

2.06

—

Mealtime routine

.13**

Total child consumption of fruits and vegetables

.18***

2.24***

Caregiver feeding style—teaching and modeling

.37***

.40***

Caregiver feeding style—emotion regulation/pressure

2.10*

2.10*

2.08

*p , .05, **p , .01, ***p , .001.

Vol. 35, No. 1, January 2014

© 2013 Lippincott Williams & Wilkins

55

regulation strategies, CFPs, FMRs, and children’s food consumption. Table 2 depicts correlations among all study variables for the pooled imputed data. Consistent with attachment theory, insecure caregivers were significantly more likely to report using negative emotion regulation strategies in response to their children’s distress than less insecure parents. With respect to FMRs, insecure caregivers reported having planned mealtimes less often and that their children watched significantly more television than less insecure parents. Attachment scores also significantly correlated with CFPQ feeding styles. Caregivers who were more insecure reported using emotion feeding/pressure practices more frequently than less insecure parents. As hypothesized, negative emotion regulation was significantly associated with CFPQ emotion feeding/pressure, whereas positive emotion regulation significantly correlated with CFPQ teaching/modeling feeding styles. Consistent with the previous literature, both FMR and child TV viewing were significantly associated with children’s consumption of both unhealthful and healthful foods in expected directions (Table 2). Additionally, CFPQ emotion feeding/pressure and CFPQ teaching/modeling were found to correlate significantly with children’s consumption of healthful and unhealthful foods in expected directions (Table 2). Finally, bivariate correlations revealed that relatively more insecure caregivers reported that their children consumed significantly more unhealthful foods, and children’s consumption of fruits/vegetables was significantly and negatively associated with negative emotion regulation and significantly and positively associated with positive emotion regulation (Table 2).

BMI, race, education level, caregiver depression, and anxiety. Table 3 shows estimates for all of the statistical controls in each model for the unhealthful food consumption outcome. Results of the serial mediation model of the relations between insecure attachment, negative emotion regulation, emotion feeding/pressure CFPs, and children’s food consumption are provided in Figure 2 and in Table 4. Path estimates support direct associations between insecure attachment and negative emotion regulation, between negative emotion regulation and emotion feeding/pressure CFPs, and between these CFPs and children’s consumption of unhealthful foods (all p , .001). The total effect of insecurity on children’s food consumption was significant (p , .05), but the direct effect was reduced (p 5 .06). The direct effects between insecurity and CFPs and between negative emotion regulation and child food consumption were not significant. Table 4 shows model summaries of the tests for indirect associations with bias-corrected confidence intervals (10,000 bootstrap samples). The hypothesized indirect effect was shown to be significant (i.e., attachment insecurity . negative emotion regulation . emotion CFPs . unhealthful food consumption) and indicated by the 95% confidence interval not containing zero.48 No other indirect effects were found to be significant. Model 2 tested emotion regulation and FMR as mediators of the relations between insecure attachment and children’s food consumption. These results are presented in Figure 3 and in Table 4. All direct path estimates were found to be significant except the insecurity . FMR and the negative emotion regulation . unhealthful food consumption estimates. As in Model 1, the direct effect of insecurity on food consumption was slightly reduced from the total effect. Table 4 reveals the indirect effect estimates and bias-corrected confidence intervals for Model 2. The insecurity . negative emotion regulation . FMR . food consumption indirect path was significant and indicated by the confidence interval not containing zero. No other indirect associations were found to be significant. Our final model examined emotion regulation and child TV viewing as mediators of the relations between

Model Testing Our theory-driven hypothesized models were tested using PROCESS, a statistical tool for multiple mediation, moderation, and conditional process modeling with observed variables.48 PROCESS provides estimations of direct and indirect effects and uses asymmetric, biascorrected bootstrap confidence intervals for the quantified indirect effects.48 In all 3 models, covariates included child age, child gender, caregiver age, caregiver

Table 3. Coefficient Estimates for Statistical Controls on Unhealthful Food Consumption Model 1 Variable Parent age Parent body mass index Education

Model 2 t

Coefficient

SE

2.0010

.0047

.0126

.0059

2.1415*

2.1526

.0336

24.5134***

20.2136

Model 3 t

Coefficient

SE

2.0036

.0047

.0091

.0058

1.5578

2.1397

.0343

24.3296***

20.7675

t

Coefficient

SE

2.0027

.0047

.0054

.0058

0.9128

2.1315

.0348

23.7765***

20.5658

Race

2.2298

.0475

24.8365***

2.2226

.0482

24.6731***

2.2048

.0493

24.1340***

DASS-depression

2.0219

.0774

20.2222

2.0076

.0784

20.0974

2.0326

.0779

20.41922

DASS-anxiety

2.0326

.1050

20.3153

2.0318

.0163

20.3029

2.0451

.1032

20.4410

Child age

.0070

.0046

1.5492

.0086

.0046

1.8409

.0056

.0047

1.1874

Child gender

.0389

.0623

0.6268

.0334

.0630

0.5323

.0639

.0628

1.0202

DASS, Depression Anxiety Stress Scales; SE, standard error. *p , .05, ***p , .0001.

56 Adult Attachment and Children’s Food Consumption

Journal of Developmental & Behavioral Pediatrics

Figure 2. Path analysis results for the serial mediation model of the relations between insecure attachment, emotion regulation, feeding practices, and children’s unhealthful food consumption. Covariates include caregiver age, caregiver body mass index, caregiver depression, caregiver anxiety, caregiver education, race, child age, and child gender. Standard errors are given in parentheses.

insecure attachment and children’s unhealthful food consumption. These results are presented in Figure 4 and in Table 4. All direct paths were significant except the negative emotion regulation . TV viewing and negative emotion regulation . food consumption paths, and the direct effect of insecurity on children’s food consumption (p , .06) was reduced from the total effect (p , .05). Indirect effect estimates and bias-corrected confidence intervals for Model 3 are presented in Table 4. Only the insecurity . child TV viewing . food consumption indirect path was found to be significant and indicated by the confidence interval not containing zero.

DISCUSSION Although recent studies have revealed longitudinal associations between child attachment and obesity, the Table 4. Summaries for Indirect Effects with Bias-Corrected 95% Confidence Intervals (10,000 Bootstrap Samples) Model Model 1

Indirect Effects Boot SE Boot LLCI Boot ULCI 2.00018

a

b

.00896 * .00606 Model 2

.00656

c

d

e

.00256 * .00748 Model 3

.00600 .00314

f

g

h

i

.02836 *

.00926

2.01894

.01856

.00386

.00342

.01946

.00972

2.01102

.02842

.00928

2.01000

.02748

.00182

.00032

.00834

.00718

2.00126

.02862

.00896

2.01052

.02572

.00216

2.00024

.00932

.01306

.00848

.06116

effect results for insecurity . negative emotion regulation . unhealthful food consumption. bIndirect effect results for insecurity . negative emotion regulation . emotion regulation/food as reward feeding styles . unhealthful food consumption. cIndirect effect results for insecurity . emotion regulation/ food as reward feeding styles . unhealthful food consumption. dIndirect effect results for insecurity . negative emotion regulation . unhealthful food consumption. eIndirect effect results for insecurity . negative emotion regulation . mealtime routine . unhealthful food consumption. fIndirect effect results for insecurity . mealtime routine . unhealthful food consumption. gIndirect effect results for insecurity . negative emotion regulation . unhealthful food consumption. hIndirect effect results for insecurity . negative emotion regulation . television viewing . unhealthful food consumption. iIndirect effect results for insecurity . TV viewing . unhealthful food consumption. *p , .05. LLCI, lower limit confidence interval; SE, standard error; ULCI, upper limit confidence interval. aIndirect

Vol. 35, No. 1, January 2014

mechanism accounting for these associations has not been documented. Because attachment insecurity is a primary marker of ineffective emotion regulation in early childhood, emotion regulation may be a promising mechanism to explore.10 In this study, we examined whether parental insecure attachment and emotion regulation strategies have implications for children’s eating behaviors. We first explored associations between caregiver adult attachment style, emotion regulation, and children’s food consumption. Second, we examined possible mechanisms through which attachment may affect children’s food consumption by testing 3 theory-driven serial mediation models. It was hypothesized that caregiver insecurity would be characterized by ineffective (e.g., punishing, minimizing) responses to children’s negative affect and that these emotion regulation strategies would increase the likelihood of several obesogenic practices: negative caregiver feeding practices, lack of family mealtime routines (FMRs), and child television (TV) viewing. These practices, in turn, were hypothesized to predict children’s consumption of unhealthful foods. As expected, based on attachment theory,9 bivariate correlations confirmed strong associations between caregiver insecurity and negative emotion regulation strategies (e.g., punitive, minimizing) in response to children’s distress. Beyond these expected associations, one clear contribution to the pediatric obesity literature is the set of findings also revealing the connections between insecurity, emotion regulation, and factors that have been shown to increase obesity risks. For example, insecure parents were less likely to have FMRs, allowed significantly more television time, and reported emotion regulation/pressure caregiver feeding practices (CFPs) more often than less insecure caregivers. Importantly, more insecure caregivers also reported that their children consumed significantly more unhealthful foods, such as salty snacks, sugary drinks, and fast food. To our knowledge, these are some of the first data to show connections © 2013 Lippincott Williams & Wilkins

57

Figure 3. Path analysis results for the serial mediation model of the relations between insecure attachment, emotion regulation, mealtime routine, and unhealthful food consumption. Covariates include caregiver age, caregiver body mass index, caregiver depression, caregiver anxiety, caregiver education, race, child age, and child gender. Standard errors are given in parentheses.

between individual differences in parental adult attachment style and their children’s food consumption, and they add to the extant literature examining parental influences on young children’s energy intake.1 In addition to attachment, emotion regulation strategies used by parents predicted important food-related practices. Caregivers who responded more negatively to children’s distress had fewer FMRs, were more likely to use emotion-related CFPs, and permitted significantly more TV viewing when compared with less negative parents. Interestingly, negative emotion regulation was not directly associated with unhealthful food consumption, but it was significantly and negatively related to children’s fruit and vegetable consumption. Alternatively, caregiver positive emotion regulation was significantly associated with children’s consumption of fruits and vegetables and to caregiver feeding styles characterized by teaching about healthy foods, modeling healthy eating, and providing a variety of foods at meal-

time. Taken together, these data suggest that insecure attachment may put parents at risk for using negative emotion regulation strategies in response to their children’s distress, which may impact the interpersonal environment surrounding food and the development of children’s early eating behaviors. Another goal was to test specific hypotheses regarding mechanisms through which adult attachment may affect children’s eating behaviors. We expanded previous research8,10 by considering how caregiver adult attachment style and emotion regulation strategies might influence the socialization of children’s eating behaviors. Model 1 revealed significant total effects of caregiver insecurity on children’s unhealthful food consumption. However, this direct effect was slightly reduced when the serial mediators (and covariates) were considered. With respect to indirect effects, only the multiple mediation effect was significant, revealing that insecure parents were more likely to respond to their children’s

Figure 4. Path analysis results for the serial mediation model of the relations between insecure attachment, emotion regulation, child television viewing, and unhealthful food consumption. Covariates include caregiver age, caregiver body mass index, caregiver depression, caregiver anxiety, caregiver education, race, child age, and child gender. Standard errors are given in parentheses. 58 Adult Attachment and Children’s Food Consumption

Journal of Developmental & Behavioral Pediatrics

distress in punishing or minimizing ways and that these negative responses increased caregivers’ emotion feeding/pressure CFPs which, in turn, predicted children’s consumption of unhealthful foods. These findings suggest that individual differences in parent attachment and associated emotion responses may set the stage for parents’ use of emotion-related CFPs even in the early preschool years. This is critical information because preschoolers are more likely to eat salty snacks/sweets beyond satiety when their mothers report using emotion CFPs.26 Our findings also support the notion that caregiver insecurity and negative responses to distress might hamper parenting skills needed to establish family FMRs. It is much easier to plan and implement shared mealtimes with preschoolers when normative emotional challenges can be addressed openly and dealt with effectively. In turn, FMR was a predictor of children’s unhealthful eating behaviors. This serial, indirect effect supports a growing body of literature documenting the importance of family routines in the development of children’s healthy habits29 and that individual differences in attachment contribute to socialization behaviors surrounding family mealtimes. Indeed, the earliest attachment experiences involve parental sensitivity to hunger and distress signals.9 Although the serial indirect effect models were found to be significant when CFPs and mealtime routine were second mediators, only the insecure attachment . total TV viewing . unhealthful food consumption indirect path was found to be significant in Model 3. These findings suggest that caregiver insecurity can affect children’s TV viewing more directly perhaps as a way of rejecting bids for interaction or dismissing/avoiding negative affect. Child TV viewing, in turn, predicted children’s consumption of unhealthful foods. These findings contribute to the study of pediatric obesity in several ways. First, they support a growing body of literature underscoring the importance of family routines in the reduction of obesogenic behaviors. For example, Anderson and Whitaker30 documented associations between 3 household routines (shared mealtime, TV viewing, and sleep duration) and the body mass index (BMI) of older preschoolers (4-year olds). However, these routines were not linked to children’s eating behaviors. The findings from this study document associations between FMRs, child TV viewing, and children’s unhealthful food consumption. Importantly, they also shed light on possible mechanisms through which parentchild interactions may translate into obesogenic practices. These data expand recent findings in the pediatric literature regarding emotion regulation and childhood obesity, but there are limitations to this study. First, the data are correlational and cross-sectional, and thus, causal relations cannot be inferred. Interpretation of the mediation analyses, in particular, should be made with caution. That said, this study set out to test specific models that were grounded in attachment theory and Vol. 35, No. 1, January 2014

partially supported by previous study findings regarding specific mechanisms linking attachment and obesity. We believe that this is a reasonable rationale for the mediational modeling. Future longitudinal studies are needed to test the hypothesized direction of causal influences in these models. Second, these data were all self-report of caregivers’ perspectives of their own behavior and their children’s behavior. Clearly, using multiple methods to assess study constructs would be beneficial to reduce shared method variance. For example, future studies that include observations of children’s dietary intake and/or dietary recalls and also parent-child emotion regulation strategies would greatly enhance these survey findings. In addition, studies that examine adult and child attachment with multiple assessments (e.g., Adult Attachment Interview, Strange Situation procedure) are needed to further identify mechanisms through which early socialization may translate into obesity-related behaviors. Finally, the majority of participants in this study were white with some college education. Future studies need to replicate these findings in more economically and ethnically diverse samples. Despite these limitations, our data contribute to the understanding of pediatric obesity in several ways. They document the role of attachment histories in the socialization of children’s eating behaviors. We know that there are biological and socialization influences on children’s self-regulation of energy intake,17 but we have little information regarding the mechanisms that account for these associations. Our findings suggest that parent adult attachment style and accompanying emotional responses to distress are associated with caregiver CFPs and capacities to implement FMRs and manage child TV viewing—all of which predict children’s unhealthful food consumption. The significant associations between insecurity, emotion regulation, and factors that have been shown to increase obesity risks also suggest the importance of attending to emotion regulatory processes in the prevention of pediatric obesity. In the clinical setting, parents’ own emotion regulation strategies and attachment styles must be addressed because these underpin parenting behaviors implicated in the interpersonal environment surrounding food and the development of children’s early eating behaviors.8 Clinicians should encourage parents to be mindful of the degree to which their own emotion regulation impacts their parenting behaviors and ultimately their children’s health.8,21,28 The Dix49 model of the affective organization of parenting could be a useful educational framework for brief practitioner contacts. When children express emotion, parents appraise those expressions and experience their own emotions which are, of course, influenced by their past experiences49 including their attachment histories.9,13 Parental emotion regulation moderates these 2 processes, and those who effectively manage their own arousal to negative child emotions are better able to remain calm and responsive to their children.13,49 © 2013 Lippincott Williams & Wilkins

59

Strategies such as reappraisal (seeing child’s negative emotion as normal and even sometimes desirable) and mindfulness (e.g., concentration on the present moment and attentiveness to emotions without judgment) can be recommended.49,50 Referral to effective programs can also be useful. Obesity interventions, such as Lifestyle Triple P,51 have demonstrated the utility of targeting parenting as a support for children’s social and emotional well-being. More general parenting programs, such as Tuning in to Kids,52 directly target emotion socialization practices of parents of preschool-aged children. Based on the findings of this study, the inclusion of such components in the clinical context should prove useful in the prevention of pediatric obesity.

14. 15.

16. 17. 18.

19.

20.

The STRONG Kids Team The team includes the following: Kristin Harrison, Kelly Bost, Brent McBride, Sharon Donovan, Diana Grigsby-Toussaint, Juhee Kim, Janet Liechty, Angela Wiley, Margarita Teran-Garcia, and Barbara Fiese. REFERENCES 1. Anzman SL, Rollins BY, Birch LL. Parental influence on children’s early eating environments and obesity risk: implications for prevention. Int J Obes (Lond). 2010;34:1116–1124. 2. Harrison K, Bost KK, McBride BA, et al. Toward a developmental conceptualization of contributors to overweight and obesity in childhood: the six-cs model. Child Dev Perspect. 2011;5:50–58. 3. Ogden CL, Carroll MD, Kit BK, et al. Prevalence of obesity and trends in body mass index among US children and adolescents, 1999-2010. JAMA. 2012;307:483–490. 4. McCarthy A, Hughes R, Tilling K, et al. Birth weight; postnatal, infant, and childhood growth; and obesity in young adulthood: evidence from the Barry Caerphilly Growth Study. Am J Clin Nutr. 2007;86:907–913. 5. Davison KK, Birch L. Obesigenic families: parents’ physical activity and dietary intake patterns predict girls’ risk of overweight. Int J Obes Relat Metab Disord. 2002;26:1186–1193. 6. Hughes S, Power T, Fisher J, et al. Revisiting a neglected construct: parenting styles in a child-feeding context. Appetite. 2005;44:83–92. 7. Kitzmann KA, Dalton WT III, Stanley CM, et al. Lifestyle interventions for youth who are overweight: a meta-analytic review. Health Psychol. 2010;29:91–101. 8. Frankel LA, Hughes SO, O’Conner TM, et al. Parental influences on children’s self-regulation of energy intake: insights from developmental literature on emotion regulation. J Obes. 2012;2012: 327259. Epub March 28, 2012. doi:10.1155/2012/327259. 9. Bowlby J. Attachment and Loss: Loss, Sadness and Depression. Vol 3. New York, NY: Basic Books; 1980. 10. Anderson SE, Gooze RA, Lemeshow S, et al. Quality of early maternal-child relationship and risk of adolescent obesity. Pediatrics. 2012;129:132–140. 11. Anderson SE, Whitaker RC. Attachment security and obesity in US preschool-aged children. Arch Pediatr Adolesc Med. 2011;165: 235–242. 12. Cassidy J. The nature of the child’s ties. In: Cassidy J, Shaver P, eds. Handbook of Attachment: Theory, Research, and Clinical Applications. 2nd ed. New York, NY: Guilford Press; 2008: 3–22. 13. Mikulincer M, Shaver P, Pereg D. Attachment theory and affect regulation: the dynamics, development, and cognitive

60 Adult Attachment and Children’s Food Consumption

21.

22.

23.

24.

25.

26.

27.

28. 29.

30. 31.

32.

33.

34.

35.

consequences of attachment-related strategies. Motiv Emot. 2003; 27:77–102. Kyrou I, Tsigos C. Stress hormones: physiological stress and regulation of metabolism. Curr Opin Pharmacol. 2009;9:787–793. Braet C, Van Strien T. Assessment of emotional, externally induced and restrained eating behaviour in nine to twelve-year-old obese and non-obese children. Behav Res Ther. 1997;35:863–873. Nguyen-Michel ST, Unger JB, Spruijt-Metz D. Dietary correlates of emotional eating in adolescence. Appetite. 2007;49:494–499. Johnson S, Birch L. Parents’ and children’s adiposity and eating style. Pediatrics. 1994;94:653–661. Roisman GI, Fraley RC. The limits of genetic influence: a behaviorgenetic analysis of infant-caregiver relationship quality and temperament. Child Dev. 2006;77:1656–1667. Ainsworth MDS, Blehar MC, Waters E, et al. Patterns of Attachment: A Psychological Study of the Strange Situation. Hillsdale, NJ: Erlbaum; 1978. Gunnar M, Vazquez D. Stress neurobiology and developmental psychopathology. In: Cicchetti D, Cogen D, eds. Developmental Psychopathology: Developmental Neuroscience. New York, NY: Wiley; 2006:533–577. Berant E, Mikulincer M, Shaver PR. Mothers’ attachment style, their mental health, and their children’s emotional vulnerabilities: a 7-year study of children with congenital heart disease. J Pers. 2008;76:31–66. Diamond L, Hicks A. Attachment style, current relationship security, and negative emotions: the mediating role of physiological regulation. J Soc Pers Relat. 2005;22:499–518. Warren SL, Bost KK, Roisman GI, et al. Effects of adult attachment and emotional distractors on brain mechanisms of cognitive control. Psychol Sci. 2010;21:1818–1826. Keller P, El-Sheikh M. Children’s emotional security and sleep: longitudinal relations and directions of effects. J Child Psychol Psychiatry. 2011;52:64–71. Hofer MA. Developmental psychobiology of early attachment. In: Casey BJ, ed. American Psychiatric Publishing Review of Psychiatry Series. Vol. 23. Arlington, VA: American Psychiatric Publishing Inc; 2004;1–28. Blisset J, Haycraft E, Farrow C. Inducing preschool children’s emotional eating: relations with parental feeding practices. Am J Clin Nutr. 2010;92:359–365. Ashcroft J, Semmler C, Carnell S, et al. Continuity and stability of eating behaviour traits in children. Eur J Clin Nutr. 2008;62: 985–990. Power TG. Stress and coping in childhood: the parents’ role. Parent Sci Pract. 2004;4:271–317. Fiese BH, Tomcho TJ, Douglas M, et al. A review of 50 years of research on naturally occurring family routines and rituals: cause for celebration? J Fam Psychol. 2002;16:381–390. Anderson SE, Whitaker RC. Household routines and obesity in US preschool-aged children. Pediatrics. 2010;125:420–428. Burgess-Champoux TL, Larson N, Neumark-Sztainer D, et al. Are family meal patterns associated with overall diet quality during the transition from early to middle adolescence? J Nutr Educ Behav. 2009;41:79–86. Yuasa K, Sei M, Takeda E, et al. Effects of lifestyle habits and eating meals together with the family on the prevalence of obesity among school children in Tokushima, Japan: a cross-sectional questionnaire-based survey. J Med Invest. 2008;55:71–77. Taveras EM, Sandora TJ, Shih M, et al. The association of television and video viewing with fast food intake by preschool-age children. Obesity (Silver Spring). 2006;14:2034–2041. Mendoza JA, Zimmerman FJ, Christakis DA. Television viewing, computer use, obesity, and adiposity in US preschool children. Int J Behav Nutr Phys Act. 2007;4:44. doi:10.1186/1479-5868-4-44. Conners NA, Tripathi SP, Clubb R. Maternal characteristics associated with television viewing habits of low-income preschool children. J Child Fam Stud. 2007;16:415–425.

Journal of Developmental & Behavioral Pediatrics

36. US Census Bureau. US Department of Commerce Economics and Statistics Admistration. 2010. Available at: http://www.census. gov/2010census. Accessed August 15, 2012. 37. Griffin D, Bartholomew K. Models of the self and other: fundamental dimensions underlying measures of adult attachment. J Pers Soc Psychol. 1994;67:430–445. 38. Edelstein R, Weede-Alexander K, Shaver P, et al. Adult attachment style and parental responsiveness during a stressful event. Attach Hum Dev. 2004;6:31–52. 39. Fraley RC, Roisman GI, Booth-LaForce C, et al. Interpersonal and genetic origins of adult attachment styles: a longitudinal study from infancy to early adulthood. J Pers Soc Psychol. 2013;104:817–838. [Epub ahead of print]. doi:10.1037/a0031435. 40. Roisman GI, Holland A, Fortuna K, et al. The adult attachment interview and self-reports of attachment style: an empirical rapprochement. J Pers Soc Psychol. 2007;92:678–697. 41. Fabes R, Eisenberg N, Bernzweig J. The coping with children’s negative emotions scale: procedures and scoring. Phoenix, AZ: Arizona State University; 1990. [Available from the authors] 42. Musher-Eizenman D, Holub S. Comprehensive feeding practices questionnaire: validation of a new measure of parental feeding practices. J Pediatr Psychol. 2007;32:960–972. 43. Fiese BH, Kline CA. Development of the family ritual questionnaire: initial reliability and validation studies. J Fam Psychol. 1993;6:290–299. 44. Roberts DF, Foher UG. Kids and Media in America. Cambridge, United Kingdom: Cambridge University Press; 2003. 45. Andreassen C, Fletcher P. Early childhood longitudinal study, birth cohort (ECLS-B) psychometric report for the 2-year data collection

Vol. 35, No. 1, January 2014

46.

47.

48.

49. 50.

51.

52.

(NCES 2007-084). National Center for Education Statistics IoES. Washington DC, WA: US Department of Education; 2007. Lovibond P, Lovibond S. The structure of negative emotional states— comparison of the depression anxiety stress scales (DASS) with the beck depression and anxiety inventories. Behav Res Ther. 1995;33: 335–343. Edwards JR, Lambert LS. Methods for integrating moderation and mediation: a general analytical framework using moderated path analysis. Psychol Methods. 2007;12:1–22. Hayes AF. Process: a versatile computational tool for observed variable mediation, moderation, and conditional process modeling. 2012. Available at: http://www.afhayes. com/public/process2012.pdf. Accessed June 2, 2012. Dix T. The affective organization of parenting—adaptive and maladaptive processes. Psychol Bull. 1991;110:3–25. Bailie C, Kuyken W, Sonnenberg S. The experiences of parents in mindfulness-based cognitive therapy. Clin Child Psychol Psychiatry[serial online]. January 2012;17:103–119. Available from: Academic Search Premier, Ipswich, MA. Accessed August 6, 2013. West F, Sanders MR, Cleghorn GJ, et al. Randomized clinical trial of a family-based lifestyle intervention for childhood obesity involving parents as the exclusive agents of change. Behav Res Ther. 2010; 48:1170–1179. Havighurst SS, Wilson KR, Harley AE, et al. “Tuning in to Kids”: reducing young children’s behavior problems using an emotion coaching parenting program. Child Psychiatry Hum Dev. 2012:1–18.

© 2013 Lippincott Williams & Wilkins

61