BEHAVIORAL THERAPY IN CHILDHOOD OBESITY
PARAM SHUKLA, MD (PSYCH.) (USA)
PEDIATRIC AND ADOLESCENT PSYCHIATRY, HARVARD UNIVERSITY (USA)
DIPLOMATE OF AMERICAN BOARD OF PSYCHIATRY
CONSULTING PEDIATRIC-ADOLESCENT PSYCHIATRIST
Before you start….
Before communicating with the child, parents should communicate among themselves
Agree on goals and target behaviors before presenting them in front of the child
Don’t discuss, disagree or argue in front of the child

Set clear, achievable goals and realistic expectations
REMEMBER- you want the child to succeed!!!

BEHAVIORAL THERAPY
Positive reinforcement-

Rewarding positive behaviors
Increase the chance of repeating rewarded behavior
Do it quickly after the behavior
POSITIVE REINFORCEMENT
Reward positive actions - meeting an exercise duration goal or eating less of a certain type of food and eating without the TV
Rewards should be decided by children and parents together in advance



Works well if child knows what is expected out of him
For example, giving sporting equipment as a reward may encourage more physically active behavior.

Avoid using food as a reward, especially high-calories foods.
Making them a reward may only make them more desirable.
Parents and health professionals should regularly use verbal praise.


Negative reinforcement

Mild form of punishment
Taking something away
Not allowing to watch TV etc…
Decreases the chances of repeating that behavior


Prepare a plan well in advance
Making a contract and having every family member sign it encourages commitment to a goal.
Each time dietary or exercise program not followed, take something away- TV time, video game time etc..
Daily food diary
The type of food-junk Vs healthy

Amount of food-small Vs large

With whom food was eaten- alone Vs family



What the child was feeling when eating- angry, depressed-VERY IMPORTANT TRIGGER FACTORS

What else was happening in the environment when the child was eating- TV, FIGHT IN FAMILY Etc..
STRUCTURED MEAL
Obese children often eat almost continuously, without structured meals
three meals a day and a snack.
Encourage choosing more fruits and vegetables for meals and snacks;
Limit or avoid soft drinks


TIMING..
Have set times to finish each meal
Breakfast and snack 10 minutes
Lunch and Dinner- 20 minutes
These prevents ruminating and encourages healthy eating habits
Try to get family to eat together.



Eating should be a social event without TV, during which people catch up discussing the day.
This takes the focus away from food
Watching TV during meal times is high-risk situation that encourages eating every time the TV is on – conditioned reflex!!
Educating and distracting…
Change unrealistic goals and false beliefs about weight loss and body image to realistic and positive ones.
Obese children more likely to become obese adults
Identify activities that divert children's attention away from food.
Exercise, school-related activities, hobbies, and eating with others.

Co-morbid psychiatric problems
Most common-Depression
Low self esteem
Anxiety
Avoidance
ADHD

Depression
Early identification is key
Lot of time eating food makes the child feel better temporarily
Also relieves anxiety
Turns in to a vicious cycle

Each time emotional instability is turned in to excessive eating
Excessive eating in turn causes guilt
Guilt causes further emotional instability
Depression signs
Feeling sad
Low self esteem
Crying
Irritability
Poor concentration

Suicidal thoughts and attempts
Avoiding friends and socialization
Excessive eating, sleeping
Avoiding physical activities

Emotional well being
Treat depression promptly
Referring to a child psychiatrist/psychologist
Behavioral therapy as well as pharmacotherapy
medicines
Avoid all antipsychotic if at all possible
Fluoxetine best studied and used for depression as well as in controlling weight and appetite
Start with 10 mg in AM and can be given max 60 mg /day in single, AM dose


Methylphenidate- CNS stimulant
Good for co-morbid ADHD, obesity
Controlled substance
Start with 5 mg twice a day and max 60/mg /day in 3 divided doses
Last dose before 5 pm

Atomoxetine- Norepinephrine reuptake inhibitor
Good for co morbid obesity, depression and ADHD
Start at .5mg/kg/day to max of 1.5 mg/kg/day or 100mg/day in 2 divided dosages


Closing-
Charity begins at home
Before we teach our patients, let us start doing it with our children, our family
Have a “TV turn-off day”
Don’t tell children what to do, show them how it is done!!!!

Be a good role model- you can’t ask your child not to watch TV while eating, if you keep on doing it yourself!!
Be clear
Be consistent
Be caring
LOVE WITH LIMITS !!!!!