Table 4.

Strategies for Change, Engagement and Maintenance from Parents of Positive Outlier Children

Theme	Sample Quotations
Parent Modeling/Family-level  Change	“Well, it starts out with me. I try to do it myself first. And then I incorporate it to them. Because if I’m not consistent, then I’m just going to slack off and … then they’ll just fall back into their routine. So that’s why I don’t even watch TV myself. I show them that that’s consistency.” “I had to get the entire family involved, everybody, we couldn’t just focus on him…..”
Rules/Limits	“There's no TV during dinner. There's nothing after 8pm. No drinking of anything… because after 8pm the only thing you're thinking about doing is going to sleep.” “If it’s in the house, he’s going to keep asking….If I don’t want him to have it, I just can’t have it in the house.” “I buy the food, I put it in front of them, and I stay strong.”
Consistency	“If you have rules, you have to follow through. If you have rewards, they have to be consistent; you can’t change them.” “I didn't want her to think, ‘Oh now I'm doing great, I can go back to eating the way I used to.’ Because they don't understand that you have to keep it up. They just think that once you get there, you can go back to the old ways and you'll still stay there, but that's not how it works.” “I’ll be honest. We are weak. We will back down to the fit, the temper tantrum, the everything. I think you need to stand your ground and enforce it, and I think that what needs to be reiterated to parents, is when you say no and they cry, don’t … say yes.”
Overcoming Resistance	“The hardest part was … getting him involved in certain things …. I think he was more afraid, because he didn’t know if he could succeed…. I had to, like, physically get involved with a few other mothers to bring their kids, ‘OK, all of your friends are going, so, let’s go.’ So when they go, and he sees that he’s able to do it, now, he plays all the time.” “And if the kids that are resisting, they just don’t want to do it, do it with them.” “So they struggle at the beginning or they fight. They want even a TV in their bedroom. But of course, absolutely no. And this is why.” “So like the whole thing with the snacks. ‘Well Mom, this person brings Doritos and Oreos…I want three snacks like so-and-so.’ … I'm like, ‘You want three snacks, OK.’ I pull out the celery bars and the carrots and the broccoli, and I say, ‘Here you go, three snacks. Don't forget your water.”
Positive Focus	“Instead of looking at now, you need to lose weight, I was like, you don’t need to lose weight, we need to eat better, we need to get you more active.” “We always tell her that she's beautiful and we love her just the way she is and she needs to love herself. In that same breath, we also explain, ‘That's why we need to watch what you eat, and help you make the better decisions.’” “What’s been established in our house is really a lifestyle that is about healthy food and exercise. There is never talk about diet. So they never ask for [fast food] because it’s just not a part of our lifestyle.”
Personalization/Tailoring	“My son didn’t like the organized sports, the organized activities. And so I had to find activities that he could do … I bought a trampoline on craigslist. All the kids now play in my backyard on this trampoline for hours.”
Child Involvement	“I think the biggest part of it was my wife and I kind of saying, OK, she's at an age now where she can kind of understand that what she's eating is, it's not just food, it's fuel. … She can help us make better decisions.” “Yesterday, I sat across from my son, he was drinking a yogurt. … ‘Mom, this is good for me, isn't it?’ I said, ‘…Turn the bottle around, I want you to read to me, how many grams of sugar is in that.’” “So one of our big things is my daughter cooks two meals a week. I mean, supervised, but she decides what she wants to cook and she cooks it. So getting them involved in the nutrition to teach themselves.”