Features

A family affair

Lynne Shallcross May 1, 2012

According to the Centers for Disease Control and Prevention, obesity now affects 17 percent of U.S. children and adolescents, which adds up to roughly 12.5 million kids. Since 1980, obesity prevalence among this group has almost tripled. Among children and adolescents ages 2 to 19, being overweight translates to a body-mass index (BMI) at or above the 85th percentile and lower than the 95th percentile for children of the same age and sex, while obesity signifies a BMI at or above the 95th percentile.

Mandy Perryman, coordinator of the counselor education program at Lynchburg College in Virginia, calls childhood obesity the No. 1 physical and mental health concern facing kids today. “We know about the physical damage, how kids are not expected to outlive their parents and other statistics, but these kids are suffering from more social isolation, more depression and more anxiety than other kids,” says Perryman, a member of the American Counseling Association who has been studying the topic for close to a decade.

In fact, the emotional side of childhood obesity can trap young people in a vicious circle. As Perryman explains, kids who are experiencing emotional vulnerabilities, including isolation and depression, sometimes end up eating more in an effort to cope. This can lead to them becoming even more isolated and sedentary and increase their risk of facing potential weight issues. “[And] when they become overweight,” Perryman says, “then those same issues become compounded.” Perryman became interested in the topic of childhood obesity while earning her doctorate at the University of New Mexico. She explored the relationship between parents’ weight-related perceptions and behaviors and their children’s body image and composition for her dissertation, and she has continued researching the topic of childhood obesity ever since.

Although physicians and nutritionists are perhaps more visible when it comes to addressing childhood obesity, Perryman contends that counselors can and should play a vital role as well. That’s because there is no better profession to understand and champion the family — especially from a wellness perspective — than counseling, Perryman says.

The original catalyst for a family appearing in a counselor’s office might be one child struggling with obesity, but helping the entire family achieve better health is often the main thrust of the counseling process, Perryman says. “The counselor can relate with the family and give a different perspective based on the wellness model,” she says. “We’re not looking at the deficits. We’re looking to enhance what the family can do.”

Ginny Gross, a counselor in private practice in Greenville, S.C., who specializes in weight-related disorders, says her young clients are often brought to her by concerned parents or referred to her by doctors or school counselors. Although an overweight or obese child might be her official client, she agrees with Perryman that the best counseling solution is to work with the entire family. In fact, Gross prefers to take a holistic approach that aims for lifestyle changes and includes working with others even beyond the parents. “I work with the children, their families, their doctors and a registered dietician,” says Gross, a member of ACA. “It is important to find a qualified registered dietician who is educated about eating disorders in order to help the child and parents learn about healthy lifestyle changes rather than ‘dieting’ techniques.” (Gross clarifies that she does not view obesity itself as an eating disorder. However, she says, many clients who are obese also struggle with eating disorders.) “Also, teachers can be incorporated into the mix if bullying or ADHD [attention deficit/hyperactivity disorder] are involved. It is important that the child’s pediatrician is involved in treatment to manage medications, to make sure labs and blood work are in a healthy range and to ensure they are not suggesting diet pills or a diet for the child.”

Working with parents of overweight or obese children sometimes focuses on highlighting the messages parents might be sending to their children, Gross says. For example, she says, negative messages about food or restrictive eating rules may only serve to fuel the child’s struggle with weight. Gross includes the parents in almost every session she has with an obese child. Sometimes, she also works alone with the parents.

Gross strongly advises parents against putting their children on diets. “This instills low self-confidence and decreases self-esteem to a lower point than it probably already is before the diet,” she says. “Also, teaching children dieting behaviors increases the chance of disordered eating, and research shows that diets and disordered eating often lead to diagnosable eating disorders. Even more so, it teaches children yo-yo dieting behavior from a young age. Research has found that yo-yo dieting leads to metabolic syndrome, diabetes, heart disease and even obesity.”

Perryman also contends that diets are the absolute wrong approach to take with overweight or obese children. Even for adults, she adds, diets don’t lead to lasting change. What will lead to lasting change, she says, is helping kids and families focus not just on doing something differently but thinking about it differently. Diets mean restricting yourself until you just can’t refrain anymore, Perryman says. And when you do give in, you feel guilt and shame, which might lead to more overeating. “You have to change [clients’] thinking and do some cognitive restructuring if you want the behavioral changes to last,” she says.

The work a counselor does with families might include talking about preparing and cooking meals together, eating together and exercising together, Perryman says. Gross adds that research has shown that eating together as a family decreases the chances of disordered eating and eating disorders. As explained by Perryman, disordered eating is when people use food for reasons other than nourishment, including attempts to numb themselves from pain or buffer themselves from interacting with others.

Also worth covering with the family of an obese child is how the family likes to celebrate, Perryman says. If celebrations usually focus on unhealthy food, talk with family members about how they can change some of those habits but still feel rewarded. “If a cupcake is special to me and then you substitute a carrot, it won’t work,” she says. “You have to come up with what will work with the family to feel like it’s a good exchange.” Perryman also suggests counselors explain to parents that labeling certain foods “off-limits” can actually backfire and how enforcing that mindset isn’t healthy.

Gross concurs. “I advise counselors to work with parents as much as possible on teaching children how to have a healthy relationship with food,” she says. “For example, foods should not be labeled as ‘good’ or ‘bad.’ All types of food should be allowed in the house and kept in the pantry, because when foods are restricted from anyone, the reward value increases in the brain for that food. So, when the child is exposed to that [restricted] food, they want it even more and it has more meaning.”

When meeting in session alone with parents, a counselor can also inform them that weight gain is a normal part of development, especially during puberty, Perryman says. She finds it surprising how many parents are unaware of that fact and how often weight gain during this period can lead parents to put their children on a diet. Perryman adds that the counselor might then also open up that conversation with the child and his or her parents in a session in an effort to help normalize what the child is experiencing.

Another point of discussion when meeting with parents alone is how these parents feel about themselves and talk about themselves in front of their children, Perryman says. For example, a child might begin nitpicking the way she looks if she absorbs and then mimics that behavior from her mother, Perryman explains. “We’re quick to focus on our appearance, but we need to reinforce for children that we’re proud of their values and their efforts and their accomplishments,” she says. “When we compliment them on the person they are, it takes the power away from everything being based on appearance.”

A positive approach

In addition to working with the family on healthy eating habits and increasing physical activity levels, Gross and Perryman say counselors can use cognitive behavior therapy to help a child struggling with weight issues. Weight loss often focuses on eating and exercising behaviors, Perryman says, but adding the cognitive piece helps to create lasting change for the child and family.

Gross views the counselor’s role as assisting the child to feel less isolated, develop stronger self-esteem, gain greater body acceptance and also learn to become aware of and cope with overeating triggers.

Perryman suggests having children carry a pocket-size mirror with them. If they start feeling low, Perryman says they can take it out, look into it and tell themselves something positive they’ve learned about themselves in counseling.

Taking a positive approach in working with overweight and obese children and their families is key, Perryman says. “We know that dieting children is the absolute worst thing we can do,” she says. “Restriction isn’t good for anyone, and fear is not a long-term motivator.” Counselors should take their approach from the wellness model, she says, with families encouraged to build on the strengths they already possess and to continue moving toward better health.

Perryman and Gross say although it is beneficial to have a basic knowledge of nutrition, counselors do not need to be specially trained in nutrition to work with obese children and their families. “However,” Gross says, “it is helpful to be knowledgeable about the non-diet approach to weight stabilization and what types of food children should be consuming and [to know about] not cutting out any of the food groups.”

“It is highly important for counselors to make sure children are eating all of their meals and never skipping meals, even if they do not feel hungry, and eating breakfast daily,” Gross continues. “Many children on stimulants for ADHD have suppressed appetites and do not want to eat or feel sick when they eat on their medications, but it is very important for parents and teachers to monitor these children’s eating patterns to make sure they eat an adequate amount of food. If a person doesn’t eat breakfast, their metabolism doesn’t get jump-started to where it needs to be for the day, and then they are more likely to overeat at lunch. Also, if a person skips meals or restricts food, not only does their metabolism decrease, their body goes into what we call ‘survival mode,’ which means our bodies are preserving energy and not burning energy because of a lack of intake of energy.”

Gross contends that although childhood obesity is a situation deserving of attention by counselors and society as a whole, we also need to be careful about the wording we use as a society. “We throw around the word epidemic lightly,” she says. “By talking about what a big problem [obesity] is, it can make kids feel bad. It can give them guilt and shame and make them feel there is something wrong with them.”

Although Gross says it’s worth working with children and families on changing thoughts and behaviors related to eating and exercise, and also acknowledges that environment can play a big part in a child’s struggles with obesity, she points to research showing that 50 to 70 percent of weight is genetically determined. That means certain children will have a larger uphill battle against weight gain than other children, and Gross wants counselors and society as a whole to be mindful of making a child feel at fault for being overweight.

Perryman agrees that nothing is wrong with the character of a child who is obese and says society needs to be careful not to make these children feel bad. In that same vein, when working with these children and their families, Perryman says, counselors should avoid applying labels and instead focus on empowering families and children to obtain better health.

However, Perryman acknowledges, on a societal level, childhood obesity is a problem — one she says shouldn’t be sugarcoated or downplayed because then it won’t get the attention it requires. Counselors should advocate to bring more attention to the topic, she says, because the more attention it receives, the more potential there is for change in what’s being served in school lunches, in keeping physical education classes intact even during budget cuts and in offering better nutritional options at lower prices nationwide. “If you can feed a family of four on a bucket of fried chicken but you can’t buy a healthy alternative for the same amount,” she says, “then you can’t sustain change.”

Lynne Shallcross is a senior writer for Counseling Today. Contact her at lshallcross@counseling.org.

Letters to the editor:  ct@counseling.org

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