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Running head: PSYCHOPATHOLOGY OF CHILDHOOD OBESITY

Psychopathology of Child & Adolescent Obesity


Shelina Hassanali
University of Calgary
EDPS 651 Disorders of Learning & Behaviour
November 12, 2012















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PSYCHOPATHOLOGY OF CHILDHOOD OBESITY
Psychopathology of Child & Adolescent Obesity
Obesity is a growing concern for many families, schools, and communities, as well as for
those involved in the fields of healthcare, human services, and government. Childhood obesity is
particularly concerning not only because of the associated short and long-term medical concerns,
but also because of the related social, emotional, and psychological factors. These factors will be
the focus of this paper, which will discuss the importance and relevance of the topic; recent
research regarding the link between childhood obesity and psychological disorders such as
depression, anxiety, eating disorders and social functioning; the potential bi-directionality of this
relationship; other related psychosocial factors; and practice implications which may stem from
the research.
Importance & Prevalence
Both childhood and adult obesity in Canada are currently being described by news-
media, policy-makers and government as an epidemic. Recent research has found that 31.5% or
an estimated 1.6 million Canadian children and adolescents were classified as overweight or
obese in 2009 to 2011 (Statistics Canada, 2012). These findings indicate that an estimated one in
every three children in Canada belongs to this group. There does seem to be a significant
difference in obesity rates for boys and girls, with 15.1% of boys being obese or overweight
versus 8.0% of girls (Statistics Canada, 2012).
While there is a plethora of research and public awareness in the area of the medical
concerns related to obesity, there seems to be significantly less focus on the psychopathology
and related psychosocial aspects of child and adolescent obesity (Harriger & Thompson, 2012;
Pitrou, Shojaei, Wazana, Gilbert & Kovess-Masfety, 2010; Russell-Mayhew, McVey, Bardick &
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Ireland, 2012). One explanation for this could be that the physical aspects of obesity and related
medical concerns such as diabetes, heart conditions and high blood pressure are more visible,
acute, and easier to measure than psychological aspects. Other reasons could include that the
immediate nature of medical concerns may be perceived as more important than mental health
concerns, or perhaps there is simply a lack of awareness of the outcomes associated with poor
mental health. Notwithstanding the focus on medical aspects, there is emerging research on the
psychopathology of child and adolescent obesity, and it is to this which we now turn our
attention.
Correlation with Depression and Anxiety
The American Psychiatric Association (2000) lists and describes all diagnosable
psychological disorders in detail in the Diagnostic and Statistical Manual of Mental Disorders
(DSM-IV-TR). Most often appearing in the research related to the psychopathology of childhood
obesity are depressive disorders and anxiety disorders.
Erermis et al (2004) investigated whether obesity was a risk factor for adolescent
psychopathology in general. Using three groups with 30 participants in each (clinical obese, non-
clinical obese, and control), the authors found that over half of the clinical obese adolescents in
their study had a DSM-IV diagnosis, with the highest number of diagnoses being major
depressive disorder (MDD) (n=10). Due to the small sample size, we must be careful to interpret
the results of this study. However, other studies have found similar results. In a study which
evaluated the frequency and type of psychiatric disorders in 155 obese children and youth,
authors found that 88 of the children received a DSM-IV diagnosis, the most common of which
was an anxiety disorder (Vila et al, 2004). These results are echoed in a study which examined
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PSYCHOPATHOLOGY OF CHILDHOOD OBESITY
whether adolescent obesity is associated with a risk for the subsequent development of MDD or
anxiety disorder (Anderson, Cohen, Naumova, Jacques & Must, 2007). Using a cohort of 776
youth between the ages of 9 and 18, the researchers assessed each participant four times over 20
years using structured diagnostic interviews. They found that adolescent obesity among females
was associated with a higher risk for both MDD and anxiety disorders, with obese adolescent
girls being at four times more risk for the development of these disorders as compared with non-
overweight adolescent girls. In this study, the researchers did not find the same results for
adolescent males; obesity was not associated with increased risk for either disorder (Anderson et
al, 2007). The results of this study, especially the difference in correlation of psychopathology
for females versus males, are important to consider for practice. If boys and girls have different
risk profiles, we might consider different prevention and intervention options for each. One
explanation for the four-fold risk for anxiety and MDD for obese girls might be due to the focus
on perpetuation of the ideal body in various forms of media. An obese teenaged girl may feel
anxious about not fitting in with her peers or being judged, which may lead to depressive
symptoms as her self-esteem is impacted. In this case, prevention and intervention may focus on
building positive self-esteem, educating young girls about the power of the media to influence
body image, and involvement in extra-curricular activities which promote positive self-image.
The role of anxiety and depression has been further studied by Goossens, Braet, Van
Vlierberghe and Mels (2009) who studied overweight youngsters who engaged in over-eating
behaviours. The authors found that increased anxiety was associated with loss of control and
emotional eating, and that depression was associated with emotional eating but not with loss of
control. They suggest that the participants in their study used eating as a coping mechanism to
handle negative emotions, and that anxious youth are especially vulnerable to loss of control
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when eating (Goossens et al, 2009). This study has important implications for practice because it
shows that over-eating might be a coping mechanism for an underlying psychological issue.
Viewing the issue from this lens will encourage focus on working through these underlying
issues while teaching appropriate (and less harmful) coping strategies.
Although psychological interventions are important to consider, the impact of medical
procedures on physical and psychological functioning should not be overlooked. Researchers
have examined changes in depressive symptoms and health related quality of life in adolescents
with extreme obesity after they underwent bariatric surgery (Zeller, Modi, Noll, Long & Inge,
2009). They found that post-operatively, there was a significant improvement in depressive
symptomology, at least in the first year following surgery. Although the sample size in this study
was small (n=31), and we do not know the longer-term outcomes past one year, this study
reminds us that there are also some cases in which medical procedures alone (without the use of
psychological interventions) can, in fact, be effective. This being said, it could be hypothesized
that the best course of action may be to explore various combinations of psychological and
medical interventions, depending on the needs of each individual client.
Correlation with Eating Disorders
Given the implicit relationship of obesity with food, it makes sense to consider the
correlation between childhood obesity and eating disorders. The DSM-IV lists anorexia nervosa
and bulimia nervosa as the two main eating disorders (APA, 2000). Currently, binge-eating
disorder is one of the disorders in the DSM-IV appendix; however it will be included as a formal
eating disorder in the DSM 5 (APA, 2012). This is a significant change and highlights the
distinct nature of binge eating as compared to other eating disorders. While individuals with
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binge eating disorder have varying degrees of obesity, it has been observed that in weight-control
clinics, individuals with this eating pattern are more obese, and this pattern has also been
observed in non-clinical community samples (APA, 2000).
Many recent studies have found a correlation between childhood obesity and eating
disorders, specifically in the areas of bulimia and binge eating (Cebolla, Perpina, Lurbe, Alvarez-
Pitti & Botella, 2012; Decaluwe & Braet, 2003; Hayden-Wade et al, 2005; Wildes et al, 2010).
In one study of 70 children and adolescents attending treatment for pediatric obesity, it was
found that 6% of participants met the criteria for binge eating disorder and 14% showed
subclinical forms of the disorder (Cebolla et al, 2012). A similar-sized study examined the risk
for developing eating disorders in 81 adolescents participating in an internet-based weight-loss
program (Doyle, le Grange, Goldschmidt & Wilfley, 2007). The authors found that 56.8% of the
participants were at risk for developing eating disorders and of these, 52.2% reported binge
eating at least once in the past month. While engaging in this behaviour once per month is not
enough to warrant a diagnosis according to DSM-IV criteria it is important to consider the
number of young people engaging in binge eating behaviours, as these have the potential to grow
into disorders with time. This research can inform our practice in the realm of early intervention
and prevention; if we can screen for these behaviours in their pre-clinical stage, we may be able
to intervene with children and adolescents purging and binge-eating behaviours before they
become eating disorders.
Bi-directionality of Obesity and Psychological Disorders
As discussed, the literature has shown a correlation between child and adolescent obesity
and psychological conditions, including depression, anxiety, and eating disorders. The question
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has been raised, however, as to whether this relationship is bi-directional; that is, do the
psychological disorders cause the obesity, or does the obesity cause the psychological disorders
(Anderson et al, 2007; Erermis et al, 2004; Merten, Wickrama & Williams, 2008; Russell-
Mayhew et al, 2007). The suggestion that depression, anxiety, and eating disorders may function
as both antecedents and consequences of obesity is certainly plausible, and leads us to question
which comes first. Research has shown that depressed or anxious youngsters may turn to food as
a coping mechanism to reduce negative emotions (Goossens et al, 2009), and this over-eating
could lead to obesity. On the other hand, being overweight or obese may cause decreased self-
esteem, distorted body image or increased isolation, therefore leading to depression or anxiety.
Also, the relationship could quite easily turn into a pattern of the antecedent leading to the
consequence, and the consequence leading back to the antecedent. It seems that the correlation
between the two is indeed bi-directional and cyclical, and should be considered on an individual
basis with each client. Also, factors other than diagnosable disorders may also play a role in
perpetuating this cycle, especially for children and adolescents who are at very important
developmental stages. It is worthwhile to spend some time discussing these factors.
Related Psycho-Social Factors
While negative psychological features associated with obesity can be detrimental at any
age, the effects felt during childhood and adolescence may be especially salient considering the
already sensitive developmental period. In a French-based school study of 1030 children aged 6-
11 years, parent-child reports of a large range of psychopathological outcomes related to weight
showed a strong association between overweight and poor social functioning, with weight bias
and stigmatization starting as early as age 6 (Pitrou et al, 2010). This early onset of weight-based
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stigmatizing behaviour indicates a need for early prevention and education in the area of body
image, acceptance, and respect for differences among very young children.
Hayden-Wade et al (2005) conducted a particularly interesting study examining the
psychosocial correlates of teasing for their sample, which consisted of 70 overweight and 86
non-overweight children between the ages of 10-14 years. The findings concluded that the
overweight children were teased more and for longer periods of time. The authors state that,
When examining frequency, intensity, source and content of teasing, it is clear that the teasing
experience is more intense for overweight vs. non overweight children (p. 1387). These findings
may encourage teachers and other professionals to take a look at their existing practices
regarding teasing in schools, especially in regards to the teasing of obese or overweight students.
Analysis of the data in the above study also showed increased social withdrawal,
loneliness, isolation, lower self-confidence, and poor body image in these children (Hayden-
Wade et al, 2005), factors which have also been found in other studies of child and adolescent
obesity (Erermis et al, 2004; Harriger & Thompson, 2012). Furthermore, some studies have
found that obesity in adolescence negatively affects psychosocial well-being in young adulthood,
suggesting that adolescent obesity may put individuals at risk for life-long struggles with mental
health (Merten, Wickrama & Williams, 2008). It is clear that there is extensive evidence
highlighting various psychosocial factors that are not disorders per se, but which still have a
large impact on the social functioning and self-perception of overweight and obese children and
adolescents. Given the nature of these factors, it can be hypothesized that if enough of these
psychosocial factors were compounded and persisted over time, they have the potential to lead to
the development of various psychological disorders. It is therefore important to use this research
to inform our practice, and carefully examine not only the role of diagnosed disorders but also
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that of various psychosocial factors as we plan for education and prevention programming as
well as interventions with these individuals.
Conclusion and Future Directions
With the staggering statistics regarding the current number of overweight and obese
children and adolescents in Canada, it is clear that we are in need of continued research and
resources as well as policy and practice development in this area. While there is extensive
research available regarding physical health correlates of obesity, considerably less focus has
been placed on the psychopathology of child and adolescent obesity. Strong correlations have
been found between pediatric obesity and certain psychological conditions such as anxiety,
depression, and eating disorders, including bulimia and binge-eating. It has been suggested that
these correlations are bi-directional in nature, with obesity leading to psychological disorders and
vice-versa. While the role of diagnosable disorders is an important aspect to consider, equally
important are other psycho-social correlates such as self-esteem, body image, isolation, and peer
victimization.
Continued research in this complex issue is imperative if we hope to improve outcomes
for children and adolescents faced with obesity. It can be suggested that the best course of action
would be to focus on prevention, education, and early intervention. In addition to healthy eating
and physical activity initiatives in schools, mental health programming should also be introduced
as early as possible. Topics could include various aspects of self-esteem, body image, creating
positive support networks, teaching effective strategies to reduce and cope with anxiety,
depression and related emotions. School-based initiatives related to peer victimization and
bullying should also be assessed to determine their effectiveness for overweight or obese
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students. Also, staff training regarding how best to support and promote positive physical and
mental health development of these students will be beneficial. Parental involvement and a
strong connection between home and school may also help to ensure supportive environments
and consistency. Community-based programs targeted specifically at this population may also
help to create a sense of belonging, while participation in various activities may promote healthy
lifestyles and build strong social networks, therefore reducing isolation.
Upon consideration of the existing literature in this area, it is clear that the
psychopathology of child and adolescent obesity is a complex and multifaceted topic, and an
important one for continued study. Future research in this area will be beneficial, particularly in
the areas of school and community based early intervention programming, and the effects of
such programming on future psychosocial outcomes for children and adolescents living with
overweight and obesity.








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