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Family-Based Treatment of Pediatric Obesity

Another treatment under development is family-based treatment of pediatric overweight and obesity (FBT PO). FBT PO is a specific adaptation of family-based treatment for adolescents with EDs (Eisler et al., 1997; Le Grange, Crosby, Rathouz, & Leventhal, 2007; Lock, Couturier, & Agras, 2006). Family-based treatment for EDs is a compelling intervention for youths who are obese because of its disease-based model, its explicit focus on blame reduction, and its focus on moving away from a child-directed personal responsibility paradigm and toward environmental change. Most important, it capitalizes on and strengthens parents' capacities to function as agents of change in health-related behaviors. Research has shown that most efficacious interventions include parental involvement to some degree (Jelalian & Saelens, 1999); however, there is no one-size-fits-all model of family treatment. Thus, FBT-ΡΟ modulates the quantity and quality of parental involvement on the basis of the child's developmental stage. In addition, although drawn from an ED intervention, FBT PO recognizes that obesity is not a psychiatric condition. The level of parental control in the early stages of treatment for anorexia nervosa, for example, is more extreme and speaks to the psychologically driven reduced insight and judgment in the patient (see Chapter 17, this volume). In contrast, FBT- PO allows for more parent-child collaboration in health-related decision making, the level of which is determined not by severity of illness but by developmental stage. The changes to be made in the home are also broadly health promoting and are appropriate for all family members, including nonoverweight siblings. Families are provided with information on appropriate dietary intake and given recommendations on caloric intake and physical activity. Behavioral weight loss strategies such as self-monitoring are also used to assist with weight loss. The intervention is practical, but focuses primarily on restructuring parenting styles and family member coalitions so that implementation of changes is possible. Thus, FBT-PO is first and foremost a psychological family therapy intervention.

Treatment Description

FBT-PO takes place over the course of a 24-week period during which families are seen for 16 visits. Treatment occurs in three phases during which the child or adolescent transitions to more developmentally

Table 15.1. Example Treatment Session Outline for Behavioral Weight Loss

Session

Group Aims

Behavioral Coaching Aims

1.

Introduction

Session guidelines Childhood obesity psychoeducation Structure of program

Graph weight.

Review behavioral goals for treatment.

Introduce self-monitoring. Introduce point system.

2.

Healthy eating

Traffic light plan Calorie goals Using the food reference guide

Graph and review weight change.

Provide feedback on selfmonitoring.

Introduce nine behavioral goals.

3.

Motivation system and parenting skills

Positive parenting Modeling Reward system

Graph and review weight change.

Child begins to accrue points for meeting behavioral goals.

Continue providing feedback on self-monitoring.

Points earned become contingent on weight loss.

Topic review

4.

Making your home environment healthy

Restructuring the home food environment

Graph and review weight change.

Review points earned. Topic review

5.

Red and green physical activity

Define “red” and “green” activity.

Set activity goals.

Provide information on benefits of physical activity.

Graph and review weight change.

Review points earned. Topic review

6.

Behavior chains

Antecedents and consequences of unhealthy eating behaviors How to identify a behavior chain and break it

Graph and review weight change.

Review points earned. Topic review

7.

Healthy shopping on a budget/choosing foods wisely

Cooking tips

Meal planning practice activity Shopping wisely

Graph and review weight change.

Review points earned. Topic review

8.

High-risk situations (parties, holidays, and vacations)

Holiday planning Staying healthy during school breaks and vacation

Graph and review weight change.

Review points earned. Topic review

9.

High-risk situations (school lunches, restaurants, and fast food)

Parenting strategies around restaurants and fast food Eating at restaurants

Graph and review weight change.

Review points earned. Topic review

10.

Emotion or stress and eating

Link between emotions, stress, and eating Recognizing hunger cues Relaxation strategies

Graph and review weight change.

Review points earned. Topic review

11.

Lifestyle activity

Brainstorming barriers and possible solutions Activity scheduling

Graph and review weight change.

Review points earned.

12.

Problem solving

Preplanning Problem-solving skills (SOLVE/STEPS)

Topic review Graph and review weight change.

Review points earned. Topic review

13.

Relapse prevention

Defining a lapse and relapse Constructing a relapse prevention plan

Graph and review weight change.

Review points earned. Topic review

14.

Staying motivated with more physical activity

Ways to make physical activity more consistent Helping children be more active

Activity planning and scheduling

Graph and review weight change.

Review points earned. Topic review

15.

Review and planning healthy habits

Review key concepts Making healthy behaviors a habit

Graph and review weight change.

Review points earned. Topic review

16.

Teasing and body image

Body image and self-esteem Media and body image Teasing and strategies to use with children

Graph and review weight change.

Review points earned. Topic review

17.

Open forum

Open discussion

Graph and review weight change.

Review points earned. Topic review

18.

Responsibility

Discussing responsibilities of parents and children

Graph and review weight change.

Review points earned. Topic review

19.

Ordering right in the real world

Mocк restaurant and practicing ordering

How to make healthy decisions at restaurants

Graph and review weight change.

Review points earned. Topic review

20.

Graduation

Parent discussion Graduation ceremony

Graph and review weight change.

Review points earned. Review discharge and relapse plan.

Note. SOLVE = stop, outline, list, view, execute/evaluate; STEPS = stop, think, evaluate, perform, self-praise/self-assessment.

appropriate autonomy over eating and physical activity and session focus shifts from weight-related issues to broader issues related to child and adolescent development. The first eight sessions occur weekly, with the remainder of the sessions occurring biweekly. Weight is obtained at the start of each session and is graphed so it can be visually presented to the family during the session. The proportion of session time and responsibility over therapeutic tasks such as self-monitoring is dependent on the child's age, as noted earlier.

Phase 1. During the first phase of treatment, the primary objectives are to position the family to support the child and to relay information and behavioral strategies necessary to achieve weight loss, including selfmonitoring and information pertaining to dietary intake and physical activity and common causes of obesity (genetic and environmental). Several strategies are used to position the family appropriately so that they are able to support their child in weight loss, including the reduction of blame and the promotion of self-efficacy and parental unity. To attain collaboration from the family, the therapist frames the child's weight status as a crisis that requires immediate mobilization.

A family meal is conducted at the second session to assess parental feeding styles and dietary intake. Families are given direct feedback by the therapist on ways in which the meal could be improved, both nutritionally and in terms of parenting styles used to promote healthy behaviors. Families remain in Phase 1 of treatment until children are no longer gaining weight (optimally losing weight), self-monitoring is being completed, and parents feel confident in their ability to implement family-level, health-promoting changes in the home.

Phases 2 and 3. Phase 2 of treatment is intended to transfer the appropriate amount of independence and control around eating and physical activity behaviors back to the child. Autonomy is dependent on age and is negotiated with parents; however, during this phase, parental involvement should decrease and childrens self-efficacy in managing health-promoting behaviors is promoted. During Phase 2, education about dietary intake and physical activity continues, with particular focus placed on barriers encountered by the family. Phase 3 focuses on developing a maintenance plan that the family can follow to ensure continuity of health-promoting behaviors. Other issues that affect weight should also be addressed in these two phases, including binge eating, psychosocial factors related to weight and appearance, and lapses and relapses.

 
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