Longitudinal Associations Between Teasing and Health-related Quality of Life Among Treatment-seeking Overweight and Obese Youth

Chad D. Jensen; PhD ; Ric G. Steele; PhD; ABPP


J Pediatr Psychol. 2012;37(4):438-447. 

In This Article

Abstract and Introduction


Objectives To examine concurrent and prospective associations between perceptions of teasing and health-related quality of life (HRQOL) over the course of a behavioral/educational intervention and the subsequent year in a sample of overweight and obese children and adolescents.
Method A clinical sample of 93 overweight or obese youths (ages 7–17 years) and 1 parent/guardian completed measures of teasing and HRQOL at pre- and posttreatment and follow-up assessments. Structural equation modeling was used to examine the factor structure of the measures and to assess prospective associations over a 15-month period.
Results Results indicate that, concurrently, weight-related teasing is inversely associated with HRQOL and that, prospectively, HRQOL is inversely associated with subsequent teasing.
Study findings are suggestive of a directional relationship with lower quality of life predicting subsequent higher levels of teasing. Results suggest the potential for interventions designed to improve HRQOL to reduce teasing experiences for overweight and obese youth.


Teasing during childhood and adolescence, a significant threat to social and psychological well-being, has been widely studied over the past three decades. Numerous cross-sectional studies have detailed the many potentially detrimental psychosocial correlates of teasing including social anxiety, depression, loneliness, poor self-esteem, low social competence and acceptance, and academic problems (e.g., Schwartz, Groman, Nakamoto, & Toblin, 2005, Storch, Masia-Warner, & Brassard, 2003; Storch, Nock, Masia-Warner, & Barlas, 2003). Moreover, longitudinal studies have demonstrated that teasing in childhood may be associated with psychological distress and interpersonal difficulties years later in young adulthood (Ledley et al., 2006). Research examining the causes of teasing suggests that individual characteristics which increase the likelihood of being teased include physical weakness, poor social skills, internalizing and externalizing symptoms, and socially stigmatizing physical characteristics (e.g., short stature, obesity; Card & Hodges, 2008).

A growing body of literature suggests that overweight and obese youth are at particularly high risk for general and weight-specific teasing. For example, Neumark-Sztainer et al. (2002) reported that approximately 50% of a sample of overweight adolescents experienced teasing compared to less than 20% of average weight peers. Similarly, Hayden-Wade et al. (2005) found that 78% of a sample of overweight youth experienced teasing compared to 37.2% of a nonoverweight sample. Overweight youth who experience frequent teasing are at particular risk for numerous negative psychosocial outcomes, including poor self-esteem, depression, anxiety, and suicidal ideation (Eisenberg, Neumark-Sztainer, & Story, 2003; Storch et al., 2007). Furthermore, recent research has demonstrated that victimized overweight youth are less likely to be physically active (Faith, Leone, Ayers, Heo, & Pietrobelli, 2002; Jensen & Steele, 2008;), perhaps contributing to poorer subsequent weight-related health.

An additional potentially negative outcome of teasing, particularly among overweight and obese youth, is the possibility of reduced health-related quality of life (HRQOL). HRQOL encompasses a wide array of indicators of health including physical and psychological functioning, social activity, cognition, health perception, and general life satisfaction (National Institutes of Health, 2009). Among children and adolescents, HRQOL has often been conceptualized as functioning across four broad domains; physical, emotional, social, and school (Varni, Seid, & Kurtin, 2001). Given the chronic, systemic effects of pediatric overweight and obesity, HRQOL is of particular interest as an outcome measure for children and adolescents because it assesses functional impairment that may not be identifiable through objective measures such as body mass index (BMI) (Modi & Zeller, 2008).

Past studies have demonstrated that HRQOL is significantly lower among overweight and obese youth than among their average-weight peers (Schwimmer, Burwinkle, & Varni, 2003; Williams, Wake, Hesketh, Maher, & Waters, 2004), and that HRQOL may be functionally related to teasing and peer-victimization. For example, Janicke and colleagues (2007) reported that a psychosocial model including peer victimization, child depressive symptoms, and parent distress significantly predicted both parent- and child-reported HRQOL. Similarly, Stern et al. (2007) demonstrated that weight-related teasing (WRT), as measured by the Perceptions of Teasing Scale (Thompson, Cattarin, Fowler, & Fisher, 1995), was associated with decreased HRQOL in a sample of treatment-seeking obese adolescents.

Although some explanations for increased risk for teasing among overweight youth are intuitive (i.e., observable weight status increases risk for WRT), dyadic theories of peer victimization (including acts of relational aggression such as teasing) suggest that individual characteristics of victims may represent social weaknesses that bullies may exploit to gain higher status among peers (e.g., Veenstra, Lindenberg, Zujlstra, DeWinter, & Verhulst, 2007). Overweight children who evidence lower HRQOL (i.e., those with poorer social competence, school difficulties, emotional problems, and/or physical impairments) may be more likely to be targeted because they may be perceived as less able than nonobese peers to prevent or stop bullies' relationally aggressive actions. Indeed, Dyadic Theory might suggest a bidirectional association between teasing and lower HRQOL among youths with obesity: children with obesity and lower HRQOL would be expected to be easier "targets" for bullies, and such targeting would likely have a negative impact on obese youths' HRQOL. Consistent with this idea, the current study was designed to examine the possible bi-directional associations among HRQOL and teasing in a treatment-seeking sample of youths with overweight or obesity.

Several limitations to the existing literature examining the teasing—HRQOL relationship were also addressed by this study. First, both of the aforementioned studies examining the associations among HRQOL and teasing employed cross-sectional methodologies, a design that limits conclusions about causality and the stability of teasing and HRQOL over time. Moreover, previous studies (e.g., Janicke et al., 2007; Stern et al., 2007) have suggested unidirectional relationships between teasing and psychosocial outcomes. However, as noted above, Dyadic Theory (e.g., Veenstra et al., 2007) suggests that a bidirectional relationship may more accurately characterize this association, a hypothesis which can only be tested in a longitudinal data set. Third, only one of the studies located on this topic (i.e., Janicke et al., 2007) employed multiple reports of pediatric HRQOL. Incorporating parent and child report of HRQOL is important, particularly in light of mixed evidence for parent–child agreement on the PedsQL (e.g., Cremeens, Eiser, & Blades, 2006; Zeller & Modi, 2006). Finally, and consistent with only a few studies in the literature (e.g., Stern et al., 2007), the study was conducted in a sample of youths participating in one of two weight control treatments—a characteristic of the study that underscores the importance of addressing psychosocial outcomes as part of comprehensive weight management treatment for youths.

In light of these limitations in the extant literature, the current study tests a longitudinal model of the teasing–HRQOL relationship in the context of a larger investigation of the effectiveness of a treatment program for children and adolescents. The current investigation examines three hypotheses. First, it was hypothesized that treatment-seeking youth who reported more teasing would report (concurrently) poorer self- and parent-reported HRQOL than those experiencing less teasing. Second, it was expected that a bidirectional association between Teasing and HRQOL would be observed longitudinally in latent regression models. Specifically, it was hypothesized that Teasing would predict subsequent HRQOL and that HRQOL would predict subsequent teasing in latent regression analyses (Figure 1). Finally, it was anticipated that the two latent constructs (HRQOL and Teasing) and the associations between them would remain stable over the course of 1 year.

Figure 1.

Path diagram for final child-report structural model. Model Fit: χ2 (116, n = 93) = 162.23, p < .005, RMSEA = .058, NNFI = .96, CFI = .97.


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