Psychopathology has been indicated as a possible contributing factor in the development of pediatric
obesity [4]. Psychopathological symptoms often found in conjunction with pediatric obesity include
depression, anxiety, and eating disorders. Although psychopathology may be more common in
overweight children [4], it has been identified as the key cause of obesity in only a small number
of overweight children.
Clinicians should be aware of some of the more common symptoms associated with psychopathology,
such as poor concentration, low motivation, and social withdrawal [1]. Aggression and
behavioral problems are also commonly witnessed with these mental disorders [4]. In a study
conducted by Erermis et al. [4], 27% of clinically obese and non-clinically obese adolescents were
diagnosed with depressive disorders, compared with only 6% of the normal-weight control group.
In general, the frequency of diagnosis of various mental disorders such as depression, anxiety,
binge eating, and hyperactivity was significantly higher in the obese adolescents than the youths
of normal weight [4].
DEPRESSION
Depressed mood among adolescents is a risk factor for the development and persistence of obesity.
However, the relationship between obesity and depression remains controversial. Whether one
condition directly contributes to the other or whether they co-exist due to overlapping but noncausal
mechanisms remains unresolved. It is clear, however, that the treatment of one condition
can affect the other. The successful treatment of obesity can lead a decrease in symptoms of
depression. In contrast, medications used to treat depression have the potential to produce weight
gain. In cases of major depression it is usually necessary to adequately treat depression before a
patient is able to successfully participate in a program of lasting lifestyle modification for weight
management.
ANXIETY
Anxiety in overweight children is often observed in conjunction with more common psychological
disorders such as depression, poor self-esteem, and social isolation/withdrawal. Situations or events
that may trigger anxiety in overweight children are not easily identified. In a study conducted by
Morgan et al. [7], overweight children who reported episodes of uncontrollable eating were found
to have much higher levels of anxiety. Binge eaters also displayed increased feelings of depression
and poor self-esteem compared with overweight children who did not report binge-eating episodes [5].
Although anxiety is not currently identified as a sole contributing factor in pediatric obesity, a
common test that can be used for screening is the Revised Children’s Manifest Anxiety Scale [6].
Of additional concern is that overweight children are more likely to engage in risky behaviors
and to experience psychosocial distress. This detrimental behavior may be associated with the
consequences of being overweight. These consequences include weight discrimination, negative
stereotyping, and pressure to conform to certain body ideals [7]. In extreme cases, overweight
children may develop eating disorders.
EATING DISORDERS
Eating disorders are associated with cycles of weight loss and regain and are considered the
exhibition of extreme weight behavior [8]. Disorders include anorexia nervosa, bulimia, and binge
eating [8]. These types of extreme dieting can be devastating to a child’s life. The child can often
experience both physical and psychological consequences. These include menstrual irregularities
for girls, decrease in self-esteem, poor concentration, growth retardation, delayed sexual maturation,
and disturbed sleep patterns [8]. As with many other comorbid psychosocial factors, eating disorders
can also predispose the child to other risky behaviors: alcohol and drug abuse, smoking, promiscuity,
autoaggression, and suicide [9].
Eating disorders are an expression of psychosocial factors rather than an expression of how a
child feels about his or her body [8]. It is thought that lack of family support and connectedness
contribute to this behavior [10]. In a study by Fairburn et al. [10], families of bulimic patients were
found to exhibit abusive tendencies. Another study by Hodges et al. [11] determined that families
of binge-eating patients scored high in family conflict. In short, family dysfunction has been found
to increase the tendency for children to develop negative self-esteem, which may lead to extreme
weight behaviors [12].
The link between family dysfunction and unhealthy weight behavior was identified in a study
by Fonseca and colleagues [8]. The study consisted of 9402 students, 12 to 18 years of age. Of
that number, 4625 were girls, and 4417 were boys. Adolescents with body mass index (BMI) values
of less than 10 or more than 50 were excluded, as well as any who were of significantly short
stature. These students were asked to complete a survey comprising questions about health, risky
behaviors, and protective factors. Health factors included dieting and exercising. Risky behaviors
included vomiting; taking diet pills, laxatives, or diuretics; and excessive exercise. Protective factors
included family communication, parental supervision and monitoring, family connectedness, and
perceived caring and communication with other adults and friends. Behaviors were assessed over
a 1-week period, during which each question began with: “During the last week …”. Overall,
38.2% of girls versus 12.4% of boys reported dieting in that past week. In addition, girls exceeded
boys in trying to lose weight through exercise: 61.1% versus 42.8%. Likewise, more girls were
found vomiting (4.0% vs. 1.7%) and using diet pills (3.8% vs. 1.1%). Gender did not, however,
affect the use of laxatives and diuretics. Interestingly, it was also found that risk factors included
high parental supervision/monitoring. Both groups had a high risk factor when linked with sexual
abuse histories [8].
In a study by Grignard et al. [13], a group of 31 obese adolescents were administered a
questionnaire and a body dissatisfaction test and were interviewed regarding weight and body
image. Although a relationship between weight and self-image was established, the direction of
causality was not determined [13]. Therefore, the results did not confirm whether weight loss
improves the body image or improving self-esteem results in weight loss.
Although psychopathological problems are more prevalent in overweight children, not all
overweight children experience these problems. Clinicians may wish to use some common psychiatric
screening methods, including the Child Behavior Checklist, Children Depression Inventory,
Rosenberg Self-Esteem Scale, and Eating Attitude Tests [4]. A description of these tools and
methods of application is given by Johnson and von Almen in Chapter 9 of this volume.
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