Psychological Considerations in Pediatric Weight Management

Abstract

Expert panels have recommended a multidisciplinary approach for pediatric weight management programs, including consideration of psychosocial factors in the assessment and therapeutic program (1,2). Interventions should be set in a behavior modification conceptual framework that involves the child, parents, and broad family. However, evidence describing the increased prevalence of psychological difficulties among obese children and their families has mounted, and this development must also be considered in pediatric weight management. Zeller et al. (3) have studied the prevalence of psychological maladjustment in 121 black and white children and adolescents attending a clinic-based weight management program. Approximately one-third of the children and adolescents reported some psychological maladjustment, whereas about two-thirds of the mothers of these children reported some psychological maladjustment for their child. Approximately one-half of the mothers reported clinically significant psychological distress. In addition, the child's self-reported and mother-reported maladjustment was significantly associated with the mother's level of psychological distress. Negative psychosocial complications have been previously reported for obese children and adolescents. Obese children tend to suffer from low self-esteem, poor body image, depression, school performance difficulties, and learning problems more than their nonobese peers (4,5,6,7). It is not known whether these psychosocial problems develop as a consequence of the child's obesity or are factors that increase the child's vulnerability to becoming obese. Given the fact that obese children and adolescents are frequently the target of early discrimination and stigmatization, it seems likely that psychosocial problems play a role in the exacerbation of obesity, even if not involved in the initial etiology of the excess weight gain. For example, peer rejection accompanied by social isolation is associated with childhood obesity. Even young children have already developed preferences for “thinness” among their friends and playmates, ranking overweight children lowest as preferred playmates and forming negative impressions of the obese child (8,9). As the obese child ages, the effects of discrimination and stigmatization become more salient and may spread to several aspects of their life including social, economic, and educational areas (5,10). In addition, the weight gain associated with the use of some psychotropic medications may further exacerbate the obesity of the obese child with significant psychiatric pathology. However, it would be wrong to conclude that all obese children suffer psychological problems. For example, studies of the self-esteem of obese children and adolescents have been inconsistent. It has been suggested that children who blame their obesity on their own behavior suffer from lower self-esteem than those who feel that external causes (e.g., genetics, medical problems) are linked to their obesity (9,11). These differing results emphasize the need for individualized assessment when developing an intervention plan for the obese child. Poor family functioning, including difficulties with parenting skills, parental distress, and psychopathology, is also associated with pediatric obesity (12,13,14) This is consistent with the high rate of maternal psychological distress reported by Zeller et al. (3). In addition, complex links have been described between family factors and interactions and children's eating patterns. (15) These observations reinforce the need to consider childhood obesity within the context of the family. Most studies of pediatric weight management programs have specifically prescreened and excluded children and families with significant psychological problems. Reports from “real world” clinical settings, similar to that reported by Zeller et al. (3), have reported some of the difficulties of working in this setting, including the significant degree of obesity of the children on presentation to the clinic, poor compliance and follow-up, and practical problems such as poor third party payer reimbursement (16,17). Although such issues may discourage some from attempting to intervene in pediatric obesity, the increasing prevalence of obesity among children, the known high persistence of obesity as children age into adults, the known and increasing prevalence of obesity-related comorbidities, and the increasing transfer of “adult” medical conditions, such as type 2 diabetes, into the realm of pediatrics make it imperative that pediatric weight management programs address the real world issues of the children and families seeking medical help and intervention, including the potential for significant psychosocial difficulties for the child and family.