Psychological Assessment Of The Obese Child And Adolescents: Principles

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Author(s):

	Caroline Braet
	Caroline Braet, Ph.D., is a professor in the Department of Developmental, Personality, and Social Psychology at Ghent University in Belgium.
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	Sandra Verbeken
	Sandra Verbeken graduated in July 2006 as a Clinical Psychologist at Ghent University (Ghent, Belgium).
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1. Introduction

Research demonstrated that the eating behaviour of individuals with obesity consists of a wide variety of patterns like consuming high-calorie food to compensate for negative feelings, vomiting after overeating, eating at night, restrained eating, or meal skipping . If such eating patterns occur intensively or on a highly frequent base, we describe them as eating disturbances .

It may be difficult to grasp these eating behaviours, specifically when they are related to psychological factors. Nevertheless, early assessment and treatment of these behaviours in children is important as they can easily get worse and become more difficult to treat .

Therefore, the following chapter aims to summarize different disturbed eating patterns and possible psychological correlates observed in paediatric obesity. The literature identified several models that can guide a thorough psychological assessment. The models and the specific measures to be used in an assessment are discussed, as well as issues related to screening in a paediatric setting.

2. Observations of disturbed eating behaviour

2.1 Binge eating (see also chapter on Binge Eating)

Binge eating can be defined as a symptom or as part of a syndrome like Bulimia Nervosa, Binge eating Disorder, or Night Eating Syndrome . Binge eating episodes are associated with three or more of the following:  feelings of loss of control, eating much more rapidly than normal, eating until feeling uncomfortably full, eating large amounts of food when not feeling physically hungry, eating alone because of embarrassment, feeling disgusted with oneself, depressed, or very guilty after overeating .

Disturbed eating behaviours like binge eating can be (partially) explained by The Restraint Theory (see 2.2) or the Affect Regulation Theory (see 2.3), depending on the antecedents. Also the role of temperament ( more specific: reward sensitivity), developing cognitive brain factors (see 2.4), and family functioning (see 2.5) must be taken into account. They are all important in understanding the psychological mechanisms underlying increased weight. This poses many challenges in the assessment phase when a family presents their child with weight problems. After discussing the models, we will recommend screenings questions (see 3.0) and questionnaires (see 4.0) that can be used to test potential underlying mechanisms.

2.2 Restrained or Controlled eating

Both dietary restraint and dieting are prevalent in adults and children with obesity . Dietary restraint involves the cognitive preoccupation with weight, shape and food restriction. In contrast, dieting refers not only to the intention but the actual use of weight control practices to reduce energy intake . 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.

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 leads to weight increase. This pattern is also prevalent in children with obesity . 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 ‘risk variables for eating disturbances’ . However, experimental support is mixed , and the DRT can also not explain binge eating episodes when they occur in the absence of restrictive eating behaviours .

To conclude, assessing dietary restraint attitudes and dieting behaviours is of crucial importance to guide our understanding of the child’s weight problems and even more to stipulate personalized treatment. Advising children with obesity 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 .

2.3 Emotional Eating

Negative emotions due to life events or daily minor stressors affect eating behaviour in some people both during meals and via snacking . Specifically, under mild stress 30-43% of adults and adolescents tend to consume more comfort food  (i.e., energy-dense food due to high sugar and fat content) and show a more unbalanced eating pattern is . Interestingly, also a positive mood can result in increased food intake . Of note, individuals with overweight and obesity often have limited coping mechanisms, which can perpetuate overeating in response to emotions .

Since youngsters with obesity daily suffer from body dissatisfaction, weight concerns, social isolation and low self-esteem this is seen as problematic . Moreover, when individuals experience feelings of loss of control, negative emotions may lead to binge-eating even in the absence of dietary restraint.

The Affect Regulation Theory (ART) defines these observations as emotional eating. In this model, 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 .

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 treatment. In this context, also the assessment of quality of life should be included.

2.4 External Eating

Children with obesity can also show an increased responsiveness to food in the absence of dieting attitudes or emotions. For these children, external cues of food like sight, smell and taste lead to an automatic approach reaction, causing them to ignore feelings of satiety. They can be characterized as high reward sensitive (RS) , which is a biological based temperament characteristic.

According to Gray’s Reinforcement Sensitivity Theory  (RST), RS reflects functional outcomes of a specific region in the brains: 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 scores on the BIS/BAS scale and activation in brain reward areas to appetizing foods relative to bland foods . Furthermore, compared to average weight peers, youngsters with obesity show greater activation in brain reward areas in response to food stimuli and in response to food consumption , suggesting that they find palatable foods more rewarding . Therefore, we assume that RST can explain how biological based temperament characteristics are feeding a third mechanism underlying disturbed eating.

However, here also cognitive self-control processes have to be taken into account. These processes are not present in young children but develop with growing maturity and in interaction with a stimulating environment.

The dual process model posits that self-control, or the choice between going for the immediate reward (palatable food) and striving for long-term benefits (weight loss and improved health) is the product of the balance between bottom-up reward processes (temperament) and active top-down inhibitory self-control processes.  Research points at parallels between obesity and ADHD in children , and between obesity and other potentially addictive behaviours, all characterised by high RS and deficient inhibitory self-control .

In sum, children with obesity may show an increased responsiveness to food, sometimes regarded as addiction to overeating, even in the absence of dietary restraint or emotional eating. Such ‘reward driven’ external eating patterns may be considered as a probably third pathway, contributing to disordered eating behaviour. This will be at play when there is no balance between their bottom-up reward processes (temperament) and active top-down inhibitory self-control processes Consequently, assessing RS is relevant as it can further guide our understanding of disturbed eating and treatment.

2.5 Impact of family functioning  

For most children, the home-environment is the central socialization context influencing the risk of obesity in offspring. Rhee proposed three ways in which parent-child interactions can contribute to the child’s consumption and weight.  First, parents adopt different parenting strategies and feeding styles that may be related to a child’s eating behavior and weight status . Parents of children with obesity  may experience more difficulties implementing adequate daily food-rules and as a consequence choose less adequate feeding strategies . For example, research suggests that pressuring the child to eat everything on its plate instead of finishing when feeling satiety, might increase the chance of unhealthy consumption and energy intake . Second, parental (feeding) strategies are imbedded in their general parenting style . Literature consistently points towards the importance “authoritative parenting”, of both warm and responsive parenting (i.e. meeting the needs of the child) and adaptive (self-)control (i.e. implementing rules and pursuing them) are important to minimalize the risk of (additional) weight control . It contrasts “”authoritarian parenting” (i.e. with a lot of control but low responsivity) “permissive parenting” (i.e. with a lot of responsivity but a lack of control) and “dismissive parenting” (i.e. with low control as well as low responsivity), that are associated with more unhealthy eating habits and a higher BMI . Third, both the parenting (feeding) strategies and the parenting style are imbedded in the general emotional family climate . It refers to family relationships, the parent-child interaction, attachment, and the way in which families tend to handle conflict . For example, studies identified a relationship between family conflict and weight status , as well as less success during obesity treatment . Nonetheless, much of this research on family influences is correlational and direction of effects cannot be determined. The relationship between family functioning and children’s intake and weight is bidirectional, and also determined by both parent and child factors . Certain child factors can hinder parents’ attempts to either be responsive or consequent, such as child characteristics (e.g. some children have a more difficult temperament) or comorbidities (e.g. some children also show internalizing symptoms such as depressed mood or externalizing symptoms such as impulsive behaviour or aggression) . Those child factors often stand in the way when parents attempt to change eating habits, be authoritative or provide a safe emotional climate. Especially when parents are under a lot of stress, suffer from psychopathology or in interaction with their own reactive temperament .

All those parent-child interactions, as well as the personal child and parent factors can be measured easily with self-report scales or via parental reports, although it must be interpreted with caution. In order to retain from blaming the parent or the child, the perspective of “poorness of fit” (rather than pointing out who is to blame) is appropriate when assessing or even discussing the aetiology of the weight problem .

3. Psychological assessment of youngsters with obesity

The identified psychological variables can guide a more thorough paediatric assessment. First, the different possible psychological models (M) can be tested via a short interview.

M1. Does the child report eating large amounts of food or loss of control over his eating?

M2. Is the child preoccupied with restricting food, dietary restraint attitudes or severe weight and shape concerns?

M3. Does the child show emotional eating?

M4. Does the child show a high reward sensitivity (in general or specific to food cues), and/or a low self-control capacity towards food?

M5. Are there problems in the family related to the parenting of the child? Are parents indicating to experience a lot of stress, suffer from psychopathology or does the child show internalizing or externalizing problems which burden the family?

If one or more answers were positive, we must assume psychological problems and further assessment is indicated. This means involving a psychologist in the team. For the assessment, it is recommended to use a ‘multiple stage’ strategy . 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 , questionnaires are recommended for screening mental problems in children and adolescents via parental report (all ages) and child report (from 8 years). It is recommended to use age-appropriate screening measures to verify the answers elicited by the five 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 or other 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).

4. Optimal screening procedure

4.1 Screening for different psychological models included in one questionnaire

The screening procedure must be suitable, easy to use, standardized and evidence based. Therefore, to keep the screening procedure cost-effective and to minimize the burden of a long assessment procedure on a paediatric consult, we recommend short questionnaires that can easily be administered, to test different psychological models in every assessment.  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.

4.2 Multiple stage strategy

Using a multiple stage strategy, for those participants exceeding the cut-point (see 4.1) a second assessment is needed to further validate the hypotheses (for the abbreviations: please see Table 1).

Regarding M1, M2: besides the DEBQ child, a second instrument is the DEBQ parent.

If means are available: EDE-Q, Cheat, EDI or double check with the interview EDE.

Regarding M3, besides the DEBQ child, a second instrument is the DEBQ parent.

If means are available: CBCL, CDI, SPPC or double check with the interview KID-SCID.

Regarding M4, besides the DEBQ child a second instrument is the DEBQ parent,

If means are available: BIS/BAS or double check with a STROOP-task.

Regarding M5, for assessing family problems:  besides the CFQ use parental rejection measures.

If means are available: double check the child’s perspective via interview or observation.

For assessing child mental problems: a good instrument is the CBCL (parent and child version). If means are available CDI, SPPC and double check with the interview KID-SCID.

• 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 treatment, 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 eating behaviour and 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. The 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, bullying, suicidal thoughts, self-injury), 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, or has problems in the physical process of eating such as difficulty swallowing or using sensorimotor functions in an adequate way, as such, referral to appropriate services may be indicated

5. Discussion

Although we recognize that some children who suffer from obesity do not necessarily show maladaptive eating behaviours or have problems with family functioning, there is no question that the aetiology of obesity is complex. Even though energy intake and expenditure rely at the base of one’s weight status, pointing towards the importance of healthy eating as well as physical activity , energy intake and expenditure correlate with underlying psychological mechanisms at the level of the child as well as of its family.  Nonetheless, we must notice  that the psychological models only propose hypotheses and can be relevant or not for a specific child.  Future research is necessary on the heterogeneity between children, and should aim at identifying subtypes according to the different underlying models. Also, we must be aware that longitudinal, prospective research on the causality of the models is still under research and new insights can emerge every day.

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