Psychological Assessment Of The Obese Child And Adolescents: Principles
|Caroline Braet, Ph.D., is a professor in the Department of Developmental,
Personality, and Social Psychology at Ghent University in Belgium.
|View Author’s Full Biography|
|Sandra Verbeken graduated in July 2006 as a Clinical Psychologist
at Ghent University (Ghent, Belgium).
|View Author’s Full Biography|
Research demonstrated that the eating behaviour of obese individuals consists of a wide variety of patterns like eating caloric rich food to compensate for negative feelings, vomiting after overeating, eating at night, restrained eating, meal skipping (1).
It may be difficult to grasp and treat these eating behaviours specifically when they are related to psychological factors. Early assessment and treating of these problems in children is important as they can easily reach more serious levels for which more intensive and expensive interventions are required (2) and they can hinder weight loss.
Therefore, the following chapter aims to summarize psychological antecedents observed in paediatric obesity. The literature indentified several psychological models that can guide a thorough psychological assessment. There is no ‘leading’ theory and clinicians will test different hypotheses when an obese child applies for help. Restraint attitudes, emotional factors, learning mechanisms, personality and family variables will always be explored to help tailoring the treatment program to the individual needs of the child. Therefore it is recommended to construct a psychological profile of every obese child seeking treatment.
The models, the psychological factors and the specific measures to be used in an assessment will be presented. Finally, issues related to screening in a paediatric setting are discussed.
Restrained or Controlled eating
Obese children can demonstrate psychological attitudes like ‘dietary restraint’ or the cognitive preoccupation with weight, shape and food restriction. This is not the same as ‘dieting’ or the actual use of weight control practices to reduce energy intake (3). Both are prevalent in obese adults and children (4,5).
These cognitive preoccupations are often harmful. During dieting internal control of hunger and satiety is disregarded in favour of cognitive control (by the child or by the parents) over the child’s eating behaviour. However the cognitive control is often too rigid and easily disrupted and is in sharp contrast with a healthy lifestyle.
The Dietary Restraint Theory (DRT) is a psychological model that explains eating problems after following a strict diet. It was demonstrated that the cognitive control over eating often fails under distress or fatigue and that this increases the risk to overeat. This way, dietary restraint is often alternated with binge eating which lead to weight increase. This pattern is also prevalent in obese children (6). Furthermore failures of restraint behaviour may cause distress, which in turn fosters emotional eating. Therefore, since the occurrence of abnormalities in eating style are likely to increase, strict dieting and dietary attitudes are considered as psychological risk variables (7, 8).
To conclude, assessing an challenging dietary restraint attitudes and behaviour is important to guide our understanding and therapy. Advising obese children to restrain their eating without fully recognizing the history of dietary restraint attitudes may result in more rigid dieting-intentions which in turn may lead to the evidenced psychological side-effects and loss of control (9).
Negative emotions due to life events or daily minor stressors affect eating behaviour in some people (10-12) both during meals and via snacking. Specifically under mild stress, more comfort food consumption (energy-dense food due to high sugar and fat content) and a more unbalanced eating pattern is observed in 30-43% of adults and adolescents (13).
Since obese youngsters daily suffer from body dissatisfaction, weight concerns, social isolation and low self-esteem (14) there stress level is increased (15). Moreover, negative emotions are related with poorer obesity treatment outcome in some (16) but not all (14) studies.
The Affect Regulation Theory (ART) defines these observations as emotional eating (17). In this model mainly eating in the absence of hunger is considered as an effort to regulate negative emotions because food (a) provides comfort on a psychological level, (b) reduces arousal on a biological level, (c) distracts people from their emotional stage and (d) overshadows negative affect (18, 19).
To conclude, assessing emotional eating and exploring the potential underlying factors like stressors, low self-esteem, negative mood, body dissatisfaction or social isolation is relevant as it can guide our therapy. In this context, assessment of quality of life should also be included.
Reward driven eating style
Obese children can also show an increased responsiveness to food in the absence of dieting attitudes or emotions. For these children, the sight, smell, taste of food leads to an automatic approach reaction thereby ignoring feelings of satiety. They can be characterized as high reward sensitive (RS) (20).
According to Gray’s Reinforcement Sensitivity Theory (RST) (21), RS reflects functional outcomes of the behavioral activation system (BAS). Activation of BAS causes behavioural activation and a tendency to approach goals. Imaging research in adults showed a higher positive association between RS (22) and activation in brain reward areas to appetizing foods relative to bland foods (23). Furthermore, compared to average weight peers obese youngsters show greater activation in brain reward areas in response to food stimuli (24) and in response to food consumption (25) suggesting that obese individuals versus average weight counterparts find palatable foods more rewarding (26,27). Therefore, we assume that RST can explain a third mechanism underlying disturbed eating.
However, also cognitive processes have to be taken into account. The dual process model (28) posits that self-regulation or the decision to go for the immediate reward and eat palatable food or to strain for the larger future benefit of weight loss and improved health is the product of the balance between bottom up reward processes and active top down inhibitory control. Research point at parallels between obesity and ADHD in children (29-32), and between obesity and other potentially addictive behaviours, all characterised by high RS and deficient inhibitory control (33,34).
In sum, obese children may show an increased responsiveness to food, sometimes regarded as craving or addiction to overeating even in the absence of dietary restraint or emotional eating. Such ‘reward driven’ eating patterns may be considered as a probably third pathway, contributing to disordered eating behaviour. Consequently, assessing RS is relevant as it can further guide our understanding of disturbed eating and therapy.
Impact of family pathology or a comorbid psychopathology
For most children, the home-environment is the central socialization context influencing the risk of obesity in offspring. Although the dynamics between parent and child are difficult to unravel, there are three alternative mechanisms to consider.
First, parents adopt different feeding styles and strategies toward their offspring and it is reasonable to suggest that the way parents feed their children may be related to a child’s eating behavior and weight status (35). Parents of an obese child may experience more difficulties implementing adequate daily food-rules and as a consequence choose less adequate feeding strategies (36). Research suggests that parental report of restrictive feeding is paradoxically associated with increased child BMI however based on observations at mealtime a lack of parental control instead of self-reported overcontrolling over children’s nutrition emerged within overweight families (37). So, we wonder whether parents are aware of their parenting style.
It is noticeable that both positive involvement as too stringent parental involvement can be considered as dysfunctional. Since the 70’s, the lack of parental involvement was evidenced for both general parenting as feeding situations in obese families (38). The presence of ineffective rules and discipline, the use of food to reinforce a child’s behaviour, subtle signs of emotional abuse all can have adverse side-effects. Population based studies are needed before these findings can be generalized.
Second, it was shown that psychiatric pathology in mothers, but not in fathers, was associated with the severity of obesity in their children (39).
Third, much of this research on family influences is correlational and direction of effects cannot be determined. It is likely that the parent-child relationship is bidirectional, with children’s temperament also challenging parent’ feeding practices. For example, some children have a more irritable or reactive temperament or show more internalizing symptoms (e.g. anxious feelings, depressed mood, psychosomatic complaints) or externalizing symptoms (e.g. impulsive behaviour, aggression, oppositional behaviour) (40). This can be measured easily with self-report scales or parental report although it must be interpreted with caution. In obesity research, psychological problems and mental disorders have always been discussed as causes of the problem (41,42).
We propose the Diathesis-Stress Model (DSM) for understanding the interaction between child characteristics and environment for explaining mental problems in children with obesity. Being overweight as child in a society which promotes the thin ideal might lead to negative feedback, low-self-esteem and this can form a scar (a diathesis) making these children more vulnerable when confronted with new stressors (43). According to our perspective on psychopathology, the ‘spirit of the times hypothesis’ (44) (characterized by a thin ideal and strong expectations regarding school and social performances for all children) predicts a general increase of psychological problems in overweight individuals.
To conclude, in childhood obesity it is very relevant to screen for family problems, but cautiously since (1) parents do not seem properly aware of their parenting style and (2) some children can be more difficult to educate. Consequently, also child characteristics on both internalizing and externalizing symptoms should be assessed.
Psychological assessment of youngsters with obesity
The identified psychological variables can guide a more thorough paediatric
assessment. In the influential ECOG position paper “The psychological approach of the eating behaviour of children who are obese” (45) a multi stage procedure for assessment is recommended which is adopted here.
First, the different possible psychological models (M) can be tested via a short interview.
M1. Is the child preoccupied with restricting food, dietary restraint attitudes or severe weight and shape concerns?
M2. Does the child report emotional eating?
M3. Does the child show a high reward sensitivity (in general or specific to food cues), a low inhibition capacity or report to be addicted to food?
M4. Are there problems in the family related to the parenting of the child? Or, does the child show internalizing or externalizing problems?
If one or more answers were positive, we must assume psychological problems and further assessment is indicated. For the assessment of psychopathology, it is recommended to use a ‘multiple stage’ strategy (46). This approach involves the use of a screening test to select potential cases for further assessment. Since observation or interview are neither very reliable nor cost-effective methods (47), questionnaires are recommended for screening mental problems in children and adolescents via parental report (all ages) or child report (from 8 years). It is recommended to use age-appropriate screening measures to verify the answers elicited by the interview questions. To interpret the score on a screening instrument and evaluate children’s functioning, clinicians have to compare the child’s raw score with normative samples using percentiles or T-scores. Also cut-points can be used to identify an at-risk child.
For those participants exceeding the cut-point score a next assessment period involves a second administration of the questionnaire along with a structured interview.
Overall, the use of reliable, valid screening methods and if possible multi-informant testing assessing both the child and the parent’s perception on the same domains is recommended. The table below lists a selection of instruments considered to be reliable, valid and available for testing the different models. A variety of psychological questionnaires (10 minutes each), tasks (20 minutes each) and interviews (45 minutes each) can be used (see Table1). Some are completed by the child, some are filled in by the parents and for some, both a child- and parent version is available. We must acknowledge that some of these measures can only be used by psychologists (the interviews) but specifically the questionnaires can easily be assessed (digitally) and scored and can also be re-administered in follow-up. To the best of our knowledge, for each hypothesis there are different options (see table 1).
Table 1. Subscales testing psychological factors relevant in paediatric obesity assessment
Optimal screening procedure
Screening for different psychological models included in one questionnaire
To keep the screening procedure cost-effective and to minimize the burden of a long assessment procedure on a paediatric consult short questionnaires can be used. Further, one questionnaire for the child and one for the parent can often be administered to screen for the different psychological models. For this task, for example the DEBQ (child version) combined with CBCL (parent version) is most efficient as it can help to test 4-5 models at once. The children at-risk can be identified using cut-points, based on norms from a non-clinical sample. It will always be interpreted with caution as screening instruments reveal substantial false positives and false negatives. So, if means are available double check the child’s perspective via interview or observation.
Considerations for referral and the importance of good communication
In some cases it may be relevant to consider referral to a suitable qualified paediatric psychologist for more in-depth assessment and treatment. For example, when in the initial assessment disordered eating is recognized or there seem to be problems within the child or home environment that may impede progress in the therapy, and when the assessing clinician does not feel adequately skilled. A first consultation may also identify cases where the parents should be referred to adult specialists for additional assessment and support for themselves (e.g. to address coping skills, parenting skills, substance dependence, depression etc).
As parents may often not be aware of the importance of underlying psychological health for their child’s overall health, they may be reluctant to answer questions about these issues. It is imperative for the clinician to overcome this initial resistance by addressing the child and family in an appropriate child-friendly manner and to ask permission to focus on these domains as well. His ability to communicate openly and with compassion builds trust and is essential in order to gain accurate insight into child and family life. Fostering an environment of support and understanding is important in order to avoid stigmatization or discrimination of the child and family.
Red flags for referral
If initial screening identifies any issues where child protection might be of concern (emotional abuse, physical abuse, serious bullying), it is recommended that prompt referral to appropriate services is undertaken. Also, if the child gains or loose considerable weight in a period of six months referral to appropriate services may be indicated.
We must recognize that some children who are obese can be “psychologically healthy” with no addiction or eating disorders, and have a good quality of life, with preference for healthy nutrition and high intrinsic motivation for physical activity. The new paradigm of “Health @ any size” (48) has to be evaluated as an option for some, but not all children.
However, we must be aware that the psychological models propose hypotheses that can be relevant or not for a specific child. As indicated above, not all scientific issues regarding the underlying mechanisms have been investigated yet and some models have more evidence than others. In future research, we need to study whether we must separate/differentiate behavioural subtypes according to the different underlying psychological models.
Finally, psychological models need to recognize that we live in a toxic environment, which can influence the child on a macro-level, besides the psychological influences. Therefore an assessment process should also consider the role of friends, the school, the neighbourhood and the media.
- Schlundt DG, Taylor D, Hill JO, Sbrocco T, Pope-Cordle J, Kasser T, et al. A behavioral taxonomy of obese female participants in a weight-loss program. Am J Clin Nutr. 1991 May;53(5):1151-8.
- Costello EJ, Angold A. Developmental psychopathology and public health: past, present, and future. Dev Psychopathol. 2000 Autumn;12(4):599-618.
- Claus L, Braet C, Decaluwe V. Dieting history in obese youngsters with and without disordered eating. Int J Eat Disord. 2006 Dec;39(8):721-8.
- Decaluwe V, Braet C, Fairburn CG. Binge eating in obese children and adolescents. Int J Eat Disord. 2003 Jan;33(1):78-84.
- Howard CE, Porzelius LK. The role of dieting in binge eating disorder: etiology and treatment implications. Clin Psychol Rev. 1999 Jan;19(1):25-44.
- Stice E, Presnell K, Groesz L, Shaw H. Effects of a weight maintenance diet on bulimic symptoms in adolescent girls: an experimental test of the dietary restraint theory. Health Psychol. 2005 Jul;24(4):402-12.
- Hill AJ, Robinson A. Dieting concerns have a functional effect on the behaviour of nine-year-old girls. Br J Clin Psychol. 1991;30 ( Pt 3):265-7.
- Wardle J, Marsland L, Sheikh Y, Quinn M, Fedoroff I, Ogden J. Eating style and eating behaviour in adolescents. Appetite. 1992;18(3):167-83
- Herman CP, Olmsted MP, Polivy J. Obesity, externality, and susceptibility to social influence: an integrated analysis. J Pers Soc Psychol. 1983 Oct;45(4):926-34.
- Macht M. How emotions affect eating: a five-way model. Appetite. 2008 Jan;50(1):1-11.
- d’Autume C, Musher-Eizenman D, Marinier E, Viarme F, Frelut ML, Isnard P. [Eating behaviors and emotional symptoms in childhood obesity: a cross-sectional exploratory study using self-report questionnaires in 63 children and adolescents]. Arch Pediatr. 2012 Aug;19(8):803-10.
- Isnard P, Quantin L, Cortese S, Falissard B, Musher-Eizenman D, Guedeney A, et al. Bulimic behaviours and psychopathology in obese adolescents and in their parents. Int J Pediatr Obes. 2010 Dec;5(6):474-82.
- Nguyen-Rodriguez ST, Chou CP, Unger JB, Spruijt-Metz D. BMI as a moderator of perceived stress and emotional eating in adolescents. Eat Behav 2008; 9: 238-246.
- Braet C. Patient characteristics as predictors of weight loss after an obesity treatment for children. Obesity (Silver Spring). 2006 Jan;14(1):148-55.
- Stice E, Presnell K, Spangler D. Risk factors for binge eating onset in adolescent girls: a 2-year prospective investigation. Health Psychol. 2002 Mar;21(2):131-8.
- Epstein LH, Wisniewski L, Weng R. Child and parent psychological problems influence child weight control. Obes Res. 1994 Nov;2(6):509-15.
- Burton P, Smit HJ, Lightowler HJ. The influence of restrained and external eating patterns on overeating. Appetite. 2007 Jul;49(1):191-7.
- Macht M, Haupt C, Ellgring H. The perceived function of eating is changed during examination stress: a field study. Eat Behav. 2005 Feb;6(2):109-12.
- Macht M, Simons G. Emotions and eating in everyday life. Appetite. 2000 Aug;35(1):65-71.
- Carnell S, Gibson C, Benson L, Ochner CN, Geliebter A. Neuroimaging and obesity: current knowledge and future directions. Obes Rev. 2012 Jan;13(1):43-56.
- Gray, J. A. Elements of a two-process theory of learning. Oxford, England: Academic Press.1975
- Carver, C. S., & White, T. L. Behavioral-inhibition, behavioural activation, and affective responses to impending reward and punishment: The BIS/BAS Scales. Journal of Personality and Social Psychology, 1994;67:319-333.
- Beaver JD, Lawrence AD, van Ditzhuijzen J, Davis MH, Woods A, Calder AJ. Individual differences in reward drive predict neural responses to images of food. J Neurosci 2006; 26: 5160-5166.
- Bruce AS, Holsen LM, Chambers RJ, Martin LE, Brooks WM, Zarcone JR, et al. Obese children show hyperactivation to food pictures in brain networks linked to motivation, reward and cognitive control. Int J Obes (Lond). 2010 Oct;34(10):1494-500.
- Stice E, Spoor S, Bohon C, Small DM. Relation between obesity and blunted striatal response to food is moderated by TaqIA A1 allele. Science. 2008 Oct 17;322(5900):449-52.
- McGloin AF, Livingstone MB, Greene LC, Webb SE, Gibson JM, Jebb SA, et al. Energy and fat intake in obese and lean children at varying risk of obesity. Int J Obes Relat Metab Disord. 2002 Feb;26(2):200-7.
- Rissanen A, Hakala P, Lissner L, Mattlar CE, Koskenvuo M, Ronnemaa T. Acquired preference especially for dietary fat and obesity: a study of weight-discordant monozygotic twin pairs. Int J Obes Relat Metab Disord. 2002 Jul;26(7):973-7.
- Appelhans BM. Neurobehavioral inhibition of reward-driven feeding: Implications for dieting and obesity. 2009, 17: 640-647.
- Jensen, A. L., & Weisz, J. R. (2002). Assessing match and mismatch between practitioner-generated and standardized interview-generated diagnoses forclinic-referred children and adolescents. Journal of Consulting and Clinical Psychology, 70, 158-168.
- Agranat-Meged AN, Deitcher C, Goldzweig G, Leibenson L, Stein M, Galili-Weisstub E. Childhood obesity and attention deficit/hyperactivity disorder: a newly described comorbidity in obese hospitalized children. Int J Eat Disord. 2005 May;37(4):357-9.
- Cortese S, Angriman M, Maffeis C, Isnard P, Konofal E, Lecendreux M, et al. Attention-deficit/hyperactivity disorder (ADHD) and obesity: a systematic review of the literature. Crit Rev Food Sci Nutr. 2008 Jun;48(6):524-37.
- Cortese S, Bernardina BD, Mouren MC. Attention-deficit/hyperactivity disorder (ADHD) and binge eating. Nutr Rev. 2007 Sep;65(9):404-11.
- Cortese S, Isnard P, Frelut ML, Michel G, Quantin L, Guedeney A, et al. Association between symptoms of attention-deficit/hyperactivity disorder and bulimic behaviors in a clinical sample of severely obese adolescents. Int J Obes (Lond). 2007 Feb;31(2):340-6.
- Dawe S, Loxton NJ. The role of impulsivity in the development of substance use and eating disorders. Neurosci Biobehav Rev. 2004 May;28(3):343-51.
- Volkow ND, O’Brien CP. Issues for DSM-V: should obesity be included as a brain disorder? Am J Psychiatry. 2007 May;164(5):708-10.
- Golan M, Crow S. Parents are key players in the prevention and treatment of weight-related problems. Nutr Rev 2004; 62: 39-50.
- Constanzo PR WE. Domain specific parenting styles and their impact on the child’s development of particular deviance: The example of obesity-proneness. . J Clin Psychol 1984;3: 425-45.
- Moens E, Braet C, Bosmans G, Rosseel Y. Unfavourable family characteristics and their associations with childhood obesity: a cross-sectional study. Eur Eat Disord Rev 2009; 17: 315-323.
- Bruch, H. (1975). Obesity and anorexia-nervosa – psychosocial aspects. Australian and New Zealand Journal of Psychiatry, 9, 159-161.
- .Favaro A, Santonastaso P. Effects of parents’ psychological characteristics and eating behaviour on childhood obesity and dietary compliance. J Psychosom Res. 1995 Feb;39(2):145-51.
- Braet C, Claus L, Verbeken S, Van Vlierberghe L. Impulsivity in overweight children. Eur Child Adolesc Psychiatry. 2007 Dec;16(8):473-83.
- Britz B, Siegfried W, Ziegler A, Lamertz C, Herpertz-Dahlmann BM, Remschmidt H, et al. Rates of psychiatric disorders in a clinical study group of adolescents with extreme obesity and in obese adolescents ascertained via a population based study. Int J Obes Relat Metab Disord. 2000 Dec;24(12):1707-14.
- Zametkin AJ, Zoon CK, Klein HW, Munson S. Psychiatric aspects of child and adolescent obesity: a review of the past 10 years. J Am Acad Child Adolesc Psychiatry. 2004 Feb;43(2):134-50.
- Mustillo S, Worthman C, Erkanli A, Keeler G, Angold A, Costello EJ. Obesity and psychiatric disorder: developmental trajectories. Pediatrics. 2003 Apr;111(4 Pt 1):851-9.
- Puhl R, Brownell KD. Bias, discrimination, and obesity. Obes Res. 2001 Dec;9(12):788-805.
- Braet, C. The psychological approach of the eating behaviour of children who are obese. An ECOG position paper, ECOG group (2014).
- Kendall, P. C., Cantwell, D. P., & Kazdin, A. E. Depression in children and adolescents – assessment issues and recommendations. Cognitive Therapy and Research. 1989;13(2), 109-146.
- Miller WC, Jacob AV. Health at any size paradigm for obesity treatment: The scientific evidence. Obes Rev 2001;2:37 – 45