© 2014 American Psychological Association. The purpose of this case study is to describe the application and challenges of utilizing a manualized behavioral parent group intervention to address pediatric obesity in a community-based rural setting. Treatment included 21 group sessions, which focused on nutritional and physical activity education, gradual changes to healthy lifestyle behaviors, and implementation of behavioral and parenting strategies, over a 1-year period. Barriers to treatment effectiveness included the comorbidity of behavioral and emotional disorders, complex family dynamics and inconsistent parenting with multiple caregivers, limited access to mental health care and economic resources due to rurality, and limited readiness to actively engage in treatment. Despite these barriers, the child's Body Mass Index z score remained stable and clinically significant reductions in disordered eating attitudes and behaviors were observed after treatment. This case study demonstrates the challenges of conducting a manualized group intervention for pediatric obesity with fidelity and flexibility in the context of co-occurring emotional and behavioral difficulties, complex family dynamics, and rurality. Implications for pediatric obesity clinical practice in underserved settings and with complex cases are discussed.