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| ORIGINAL ARTICLE |
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| Year : 2013 | Volume
: 34
| Issue : 1 | Page : 19-24 |
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Psychiatric assessment of Children with constitutional obesity
Mohamed Nasreldin1, Amany A. Abdou1, Hannan H. El Shinnawy1, Tamer Ahmed Goueli1, Dalia A. Enaba1, Abeer Atef2
1 Department of Psychiatry, Faculty of Medicine, Cairo University, Cairo, Egypt
2 Department of Pediatrics, Faculty of Medicine, Cairo University, Cairo, Egypt
| Date of Submission | 21-Dec-2011 |
| Date of Acceptance | 20-Mar-2012 |
| Date of Web Publication | 3-Jun-2014 |
Correspondence Address:
Mohamed Nasreldin
MD, Department of Psychiatry, Faculty of Medicine, 11451, Cairo University, Cairo
Egypt
 Source of Support: None, Conflict of Interest: None  | Check |
DOI: 10.7123/01.EJP.0000414780.18214.c9
Objectives
To determine the psychiatric disorders that accompany pediatric obesity and to compare boys and girls in terms of the presence of these disorders.
Methods
This is a descriptive cross-sectional outpatient study. The study sample included 52 overweight youngsters (26 girls and 26 boys) who presented to the endocrinology clinic in Abo-elrish pediatric hospital with increased body weight. The endocrinal profile revealed no abnormality and it was established as constitutional obesity. The following tools were applied: the Anxiety Scale for Children, the Depression Scale for Children, and the Self-Concept Scale and Behavioral Checklist for Children. Weight and height were measured and the adjusted BMI was calculated.
Results
Eight (15.4%) of the children were depressed, 16 (30.8%) were moderately anxious, and 10 (19.2%) were highly anxious. Twenty-four (46.2%) of the children had a low self-concept and 28 (53.8%) had a positive self-concept. The entire sample of children had an eating disorder. Comparative results of boys and girls showed that all girls were in the primary stage, whereas the boys were distributed throughout the stages of education. Four (15.4%) boys and girls were depressed. Half of the boys were not anxious, 10 (38.5%) of the other half were moderately anxious, and four (15.4%) of them were highly anxious. Six (23.1%) of the girls had moderate anxiety and another six (23.1%) were highly anxious. Sixteen (61.5%) of the girls had a low self-concept, whereas only eight (30.8%) of the boys had a low self-concept with a statistical significance (P=0.050). Eight (30.8%) boys and girls had a withdrawal problem. Eight (30.8%) boys had anxiety/depression and only four (15.4%) girls had anxiety/depression.
Conclusion
Low self-concept and eating disorders compensated for the absence of other psychiatric comorbidities, especially depression and anxiety. Keywords: depression, eating disorder, pediatric obesity, psychiatric disorders, self-concept
How to cite this article:
Nasreldin M, Abdou AA, El Shinnawy HH, Goueli TA, Enaba DA, Atef A. Psychiatric assessment of Children with constitutional obesity. Egypt J Psychiatr 2013;34:19-24 |
How to cite this URL:
Nasreldin M, Abdou AA, El Shinnawy HH, Goueli TA, Enaba DA, Atef A. Psychiatric assessment of Children with constitutional obesity. Egypt J Psychiatr [serial online] 2013 [cited 2023 Sep 29];34:19-24. Available from: https://new.ejpsy.eg.net//text.asp?2013/34/1/19/133688 |
| Introduction | |  |
Obesity is being recognized as a serious public health concern because of its increasing prevalence in children and its many adverse health effects. Pediatric obesity is a condition in which excess body fat negatively affects a child’s health or well-being. The diagnosis of obesity is often made on the basis of BMI (Kopelman et al., 2005); however, the term overweight rather than obese is often used in children as it is less stigmatizing (Bessesen, 2008).
Concerns about body dissatisfaction and low self-esteem in obese children and adolescents, especially girls, focus on deviation from societal body shape ideals and experience of social marginalization that reflects a broader stigmatizing view of obesity (Friedman and Brownell, 1995). These have been accompanied by research examining depression, (Erickson et al., 2000), psychiatric disorders, (Lamertz et al., 2002; Mustillo et al., 2003), and quality of life (Schwimmer et al., 2003; Williams et al., 2005). However, as with biomedical risk, the psychological distress associated with childhood obesity shows variations within and between studies. Any deficit in low self-esteem, for example, depends on children’s sex, age, degree of obesity, and whether they are drawn from clinical or community samples (French et al., 1995).
| Aim of the study | | |
The present study aimed to determine psychiatric disorders that are comorbid with pediatric obesity, comparing boys and girls for these disorders, and suggesting areas for future study.
| Methods | | |
Ethical considerations
The approval of the ethical and research committees of the Department of Psychiatry Kasr EL Aini Hospital was obtained in accordance with the provisions of the World Medical Association’s Declaration of Helsinki. The consent of the participants was taken after describing the steps of assessment. Informed consent to the study procedure was signed by the parents of the children.
Study design
This is a descriptive cross-sectional outpatient study.
Study population
The study sample included 52 overweight youngsters (26 girls and 26 boys) who presented to the endocrinology clinic in the Abo-elrish pediatric hospital with increased body weight. The endocrinal profile indicated no abnormality and it was established as constitutional obesity. The male group had a mean age of 9.77 years (SD=2.46; range 5–13) and a mean intelligence quotient (IQ) of 89.62 (SD=11.08; range 65–100). The female group had a mean age of 9.54 (SD=1.75; range 6–12) and a mean (IQ) of 91.38 (SD=6.46; range 77–99). Both the groups were matched in terms of the educational level.
Study tools
- Weight and height were measured: The BMI was calculated and then matched to the (CDC) charts and was found to be in the range from the 85th to less than the 95th percentile.
- Wechsler Intelligence Scale for Children (Weiss et al., 1993): Measures the child’s IQ, general abilities, attention, and speech development.
- The Anxiety Scale for Children (El-Beblawy, 1987): A 42-question scale measuring a child’s anxiety manifestations (score<18 normal, 19–28 moderate anxiety, and >29 high anxiety). The manifest behavior, for example avoidance of specific situations, physiological responses to anxiety, and verbalization of anxiety experience.
- The Depression Scale for Children (Abd El-fattah, 1995): A 27-Question Scale covering the child’s depression symptoms such as depression, pessimism, worthlessness, anhedonia, anxiety, helplessness, weeping, suicidal ideation, low frustration tolerance, social isolation, loss of interest, hesitancy, low self-esteem, low motivation, somatic symptoms, poor school achievement and peer relation, and behavioral disturbances (score>50 has significant depression).
- The Self-Concept Scale (El-Ashwal, 1984): An 80-question scale covering four domains of self-concept: mental and academic abilities, body image, social abilities and peer relation, adaptation, feelings of anxiety, and depression or satisfaction (<46 low self-concept, >46 positive self-concept).
- Eating disorder test (Shokaire, 2000): It is a 40-question subjective test to assess eating-related behavior. The questions are answered by the following responses: agree (2 marks), to some extent (1 mark), or do not agree (0 mark). It assesses different eating disorder-related aspects such as eating behavior, weight, and body shape. A score equal to or above 20 marks is considered to indicate an eating disorder.
- Behavioral Checklist for Children (Achenbach, 1991): It consists of nine subscales, measuring variable behavioral disorders in children: withdrawal scale, somatic complaints scale, anxiety/depression scale, social problems scale, thought problems scale, attention problems scale, delinquency scale, aggression scale, and sexual problems scale. Note: In all the previous tools, validity and reliability were established, and they were also adapted for use in Egyptian children and were carried out in Arabic language (scores T>70 were significant).
Statistical analysis
Data were statistically described in terms of mean±SD, median and range, or frequencies (number of cases) and percentages when appropriate. Comparison of numerical variables between the study groups was carried out using the Mann–Whitney U-test for independent samples. For comparing categorical data, the χ2-test was performed. The exact test was used when the expected frequency was less than 5. P values less than 0.05 were considered statistically significant. All statistical calculations were carried out using computer program statistical package for the social science, version 15 for Microsoft Windows (SPSS Inc., Chicago, Illinois, USA).
| Results | | |
The educational stages of the children are presented in [Table 1], which shows that 48 (92.3%) of the total 52 children were educated. They were in kindergarten, primary, and preparatory stages. Eight (15.4%) were depressed, 16 (30.8%) were moderately anxious, and 10 (19.2%) were highly anxious [Table 1]. Twenty-four (46.2%) of the children had a low self-concept and 28 (53.8%) had a positive self-concept [Table 4]. All children had an eating disorder [Table 1]. From the items of the child checklist, no child showed delinquency or sex preference problems [Table 2]. Comparative results between boys and girls showed that all girls were in the primary stage, whereas the boys were distributed throughout the stages [Table 3]. Four (15.4%) boys and girls were depressed [Table 6]. Half of the boys were not anxious, 10 (38.5) of the other half were moderately anxious, and four (15.4%) of them were highly anxious. Six (23.1%) girls had moderate anxiety and another six were highly anxious. Sixteen (61.5%) girls had a low self-concept whereas only eight (30.8%) boys had a low self-concept with a statistical significance (P=0.050) [Table 3]. All boys and girls had an eating disorder [Table 3]. Eight (30.8%) boys and girls had a withdrawal problem [Table 4]. The majority of both boys and girls had no somatic symptoms [Table 3]. Eight (30.8%) of the boys scored as anxiety/depressed compared with only four (15.4%) girls [Table 4]. Twenty-four (92.3%) boys and girls sample showed no social problems [Table 5]. None of the girls showed attention problems, compared with only two (7.7%) of the boys [Table 6]. None of the boys or girls showed delinquency [Table 6]. None of the girls showed aggression, whereas two (7.7%) boys showed aggression [Table 6]. None of the boys or girls showed sex preference problems [Table 6]. | Table 1: Educational stages, depression, anxiety, self-concept, and eating disorder
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 | Table 5: Comparison between boys and girls in clinical and psychopathological correlates
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 | Table 6: Comparison between boys and girls in terms of the Behavioural Checklist for Children
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| Discussion | | |
Low self-concept was found to be significantly higher in girls than in boys, and this can be explained by the fact that girls perceive higher levels of social and media pressure to lose weight as pursuing a better body shape. Boys, however, perceived social and media pressure to be muscular and they preferred a larger body size for a better body shape. This was consistent with the findings of Pallan et al. (2011), which found a low self-concept (over 80%) and a significant relationship between objectively measured weight status and low self-concept body image perception and body dissatisfaction in children as young as 5. The findings of the present study were consistent with those of Button et al. (1997), Nassar et al. (1992), Franklin et al. (2006), and Ricciardelli and McCabe (2001), in which girls with lower levels of self-concept and self-esteem had higher levels of body dissatisfaction and were more likely to engage in strategies to decrease weight. In this study, only 15.4% were depressed without sex difference and this could be explained by the differences in how depression is diagnosed in children compared with adults with atypical symptomatology, irritability, cognitive dysfunction, externalizing behavioral patterns, social isolation, and low self-esteem and self-concept. Our findings are in agreement with those of Wardle and Cooke (2005), which found that symptoms of depression and guilt were found more frequently along with externalizing behavior problems in children compared with adolescents, whereas Reeves et al. (2008) reported that the core feature of depression is decreased interest and motivation for activity. Exclusive pursuit of sedentary activities promotes social isolation as well as decreased physical activity. Interpersonal problems and feelings of ineffectiveness on the Children’s Depression Inventory correlated with sedentary behavior at the ages of 11–13 years (Anton et al., 2006). Consistent with this study is that of Place et al. (2002), which attributed the absence of psychopathology in some children to the strong resilience they show so that they have access to protective or mediating factors in three broad areas: within themselves, in their families, and within the communities in which they live, where obesity can be considered as a sign of health. Thirty percent of the study sample was found to have moderate anxiety and 19.2% were found to have high anxiety, with no significant difference between boys and girls. Consistent with our finding French et al. (1995) and Warschburger (2000) reported that the clinical impression indicates that obese children might experience increased anxiety in association with obesity. However, this clinical observation did not always coincide with the results of studies. The magnitude of the association between weight status and the occurrence of psychological problems varies and suggests that obesity does not inevitably lead to psychosocial strain. The present study indicated that 100% of the patients had an eating disorder. This finding was expected and can be attributed to different factors, the heritability of eating disorders, learned behavior pattern, depressive states, and stress. Clare et al. (2011) have reported that psychological, social, and behavioral processes play a role in the development of eating behaviors during infancy and childhood, and they described the five feeding styles of eating behavior in childhood: (a) restriction of particular kinds of (unhealthy) foods or amounts of food; (b) pressure or excessive encouragement to consume more food, especially during a meal; (c) instrumental feeding – using food as a reward to manipulate behavior; (d) emotional feeding – using food to manage the child’s negative emotional states; and (e) exposure – children eat what their parents give them, and may copy their parents’ eating behaviors. Motivation to eat is a relative reinforcing value of food, whereas the prevalence of youth with a high motivation to eat is currently unknown; this appetitive trait has been detected in 8-year-old children (Temple et al., 2008). One promising substitute for food may be increased social support and social interactions with family and peers (Wilfley et al., 2007, 2010), as overweight youngsters have been found to make healthier eating and activity choices when they are in the presence of peers as compared with when they are alone (Salvy et al., 2007, 2008). This indicates that maladaptive eating behavior can be a result of negative affect and social unacceptance and isolation. Impulsivity is typically measured in youth with weight-related problems through a delay in the gratification paradigm in a laboratory setting, whereby children choose between a smaller, immediate food reward and a larger, delayed reward (Mischel et al., 1989). Reward sensitivity has been found to be a key aspect of impulsivity in obesity (Stice et al., 2002). All of the appetitive traits are similar in that such individuals have an impaired ability to regulate their energy intake; these vulnerable youth are unable to initiate eating only when they are hungry and/or terminate eating when they are full. This observation may indicate a common propensity for children and adolescent with appetitive traits to rely on external influences to determine food intake. Studies show an overlap among appetitive traits in overweight children and adolescents, including between binge eating and satiety responsiveness (Mirch et al., 2006), binge eating and impulsivity (Nederkoorn et al., 2006, 2007), and motivation to eat and impulsivity (Epstein et al., 2010). In the present study, none of the girls showed attention problems, compared with only two (7.7%) boys. This could be attributed to the lower motivation to perform, because of low self-esteem and higher impulsivity and aggressive traits in boys than girls. The findings of Braet et al. (2007) are consistent with ours in that especially overweight boys show more impulsivity, hyperactivity, and attention deficits, as well as problems with focusing attention on the attention control scale compared with their normal-weight controls. In the present study, 7.7% were found to have social problems without sex difference. This low rate of social problems might be attributed to the family and social support. One promising substitute for food may be increased social support and social interactions with family and peers (Wilfley et al., 2007, 2010), as overweight youngsters have been found to make healthier eating and activity choices when they are in the presence of peers as compared with when they are alone (Salvy et al., 2007, 2008). This indicates that maladaptive eating behavior can be a result of negative affect and social unacceptance and isolation. This study indicated that none of the girls showed aggression. This low rate of aggression can be explained by the possibility that overweight children seek social acceptance more than fighting back. Our small sample size might represent another explanation. They are likely victims of verbal taunting and teasing. Negative comments about the child needing to lose weight for peer acceptance were frequent. In studies by Epstein et al. (1994); Zeller et al. (2004), it was found in both clinical and nonclinical samples of obese youth that mother-reported externalizing or aggressive symptoms were in the nonclinical range, although at rates higher than those of non-treatment-seeking obese and/or nonobese age mates (Tershakovec et al., 1994; Braet et al., 1997; Young-Hyman et al., 2003; Erermis et al., 2004; Tanofsky-Kraff et al., 2004). Boys were more likely to suggest a more aggressive response, such as ‘he should fight back’ than the girls, with girls being more likely to suggest talking about the name-calling. This was consistent with previous research showing that girls are more positive about overweight peers (Cohen et al., 1997) and about peers in general compared with boys (Nabors et al., 2004). In this study, the majority of both boys and girls in the sample had no somatic symptoms. The absence of somatic symptoms as a part of other psychiatric comorbidities that were also absent in our study, especially depression and anxiety, could have been compensated for by other symptoms such as a low self-concept and eating disorders. The young age range and the small size may explain the finding. Consistent with our findings is a study of adolescent girls by Pesa et al. (2000), which found that after controlling for body-image dissatisfaction, the difference in somatoform, pain, and other psychopathology between nonobese and obese girls aged 15–17 years was insignificant. Erickson et al. (2000) found similar results in a study of third graders. Thus, obese children may overeat as a consequence of environmental deprivation or as a result of depression, somatization, or familial abuse (Christoffel and Forsyth, 1989; Felitti, 1993).
| Limitations | | |
The first limitation is that this is a cross-sectional study that assessed a group of overweight children and not a longitudinal study that shows different phases and relationships with psychiatric symptoms such as anxiety, depression, and self-esteem and self-concept. The second limitation is the absence of assessments of character and temperament to exclude the overlap of symptoms such as borderline traits that could have been present.
| Clinical implications | | |
Overweight during childhood is widespread and associated with harmful physical, psychological, and social problems. Therefore, it is important for health providers to be aware of the causes and consequences of eating-related and weight-related problems, considering sex differences as an important factor in the understanding of the psychopathology of overweight children.[50]
| References | | |
| 1. | Abd El-fattah G Depression scale for children. 1995 Cairo Dar El Nahda El Arabia 
|
| 2. | Achenbach TM Manual for child behavior checklist 4–18, 1991 profile. 1991 Burlington Univ Vermont/Dept Psychiatry
|
| 3. | Anton SD, Newton RL Jr, Sothern M, Martin CK, Stewart TM, Williamson DA. Association of depression with Body Mass Index, sedentary behavior and maladaptive eating attitudes and behaviors in 11 to 13-year old children. Eat Weight Disord. 2006;11:e102–e108
|
| 4. | Bessesen DH. Update on obesity. J Clin Endocrinol Metab. 2008;93:2027–2034
|
| 5. | Braet C, Mervielde I, Vandereycken W. Psychological aspects of childhood obesity: a controlled study in a clinical and nonclinical sample. J Pediatr Psychol. 1997;22:59–71
|
| 6. | Braet C, Claus L, Verbeken S, Van Vlierberghe L. Impulsivity in overweight children. Eur Child Adolesc Psychiatry. 2007;16:473–483
|
| 7. | Button EJ, Loan P, Davies J, Sonuga-Barke EJS. Self-esteem, eating problems and psychological well-being in a cohort of schoolgirls aged 15–16: a questionnaire and interview study. Int J Eat Disord. 1997;21:39–47
|
| 8. | Christoffel KK, Forsyth BWC. Mirror image of environmental deprivation: severe childhood obesity of psychosocial origin. Child Abuse Negl. 1989;13:249–256
|
| 9. | Clare L, Susan C, Jane WMoreno LA, Pigeot I, Ahrens W. Eating behavior and weight in children. Epidemiology of obesity in children and adolescents: prevalence and etiology (Springer series on epidemiology and public health). 20111st ed Springer, New York Springer:455–482
|
| 10. | Cohen R, Budesheim TL, MacDonald CD, Eymard LA. Weighing the evidence: likability and trait attributions of a Peer as a function of behavioral characteristics, body weight and sex. Child Study J. 1997;27:69–94
|
| 11. | El-Ashwal A Self-Concept Scale for children. 1984 Cairo El-Anglo Egyptian Book shop
|
| 12. | El-Beblawy V Anxiety Scale for children. 1987 Cairo El-Anglo Egyptian Book shop
|
| 13. | Epstein LH, Klein KR, Wisniewski L. Child and parent factors that influence psychological problems in obese children. Int J Eat Disord. 1994;15:151–157
|
| 14. | Epstein LH, Salvy SJ, Carr KA, Dearing KK, Bickel WK. Food reinforcement, delay discounting and obesity. Physiol Behav. 2010;100:438–445
|
| 15. | Erermis S, Cetin N, Tamar M, Bukusoglu N, Akdeniz F, Goksen D. Is obesity a risk factor for psychopathology among adolescents? Pediatr Int. 2004;46:296–301
|
| 16. | Erickson SJ, Robinson TN, Farish Haydel K, Killen JD. Are overweight children unhappy? Body mass index, depressive symptoms and overweight concerns in elementary school children. Arch Pediatr Adolesc Med. 2000;154:931–935
|
| 17. | Felitti VJ. Childhood sexual abuse, depression and family dysfunction in adult obese patients: a case control study. South Med J. 1993;86:732–736
|
| 18. | Franklin J, Denyer G, Steinbeck KS, Caterson ID, Hill AJ. Obesity and risk of low self-esteem: a statewide survey of Australian children. Pediatrics. 2006;118:2481–2487
|
| 19. | French SA, Story M, Perry CL. Self-esteem and obesity in children and adolescents: a literature review. Obes Res. 1995;3:479–490
|
| 20. | Friedman MA, Brownell KD. Psychological correlates of obesity: moving to the next research generation. Psycholo Bull. 1995;117:3–20
|
| 21. | Kopelman PG, Caterson I, Dietz W Clinical obesity in adults and children. 20052nd ed Oxford Wiley-Blackwell
|
| 22. | Lamertz CM, Jacobi C, Yassouridis A, Arnold K, Henkel AW. Are obese adolescents and young adults at higher risk for mental disorders? A community survey. Obes Res. 2002;10:1152–1160
|
| 23. | Mirch MC, McDuffie JR, Yanovski SZ, Schollnberger M, Tanofsky-Kraff M, Theim KR, et al. Effects of binge eating on satiation, satiety and energy intake of overweight children. Am J Clin Nutr. 2006;84:732–738
|
| 24. | Mischel W, Shoda Y, Rodriguez ML. Delay of gratification in children. Science. 1989;244:933–938
|
| 25. | Mustillo S, Worthman C, Erkanli A, Keeler G, Angold A, Costello EJ. Obesity and psychiatric disorder: developmental trajectories. Pediatrics. 2003;111:851–859
|
| 26. | Nabors LA, Lehmkuhl HD, Warm JS. Children’s acceptance ratings of a child with a facial scar: the impact of positive scripts. Early Educ Dev. 2004;15:79–92
|
| 27. | Nassar CM, Hodges P, Ollendick T. Self-concept, eating attitudes and dietary patterns in young adolescent girls. School Counselor. 1992;39:338–343
|
| 28. | Nederkoorn C, Braet C, Van Eijs Y, Tanghe A, Jansen A. Why obese children cannot resist food: the role of impulsivity. Eat Behav. 2006;7:315–322
|
| 29. | Nederkoorn C, Jansen E, Mulkens S, Jansen A. Impulsivity predicts treatment outcome in obese children. Behav Res Ther. 2007;45:1071–1075
|
| 30. | Pallan MJ, Hiam LC, Duda JL, Adab P. Body image, body dissatisfaction and weight status in south asian children: a cross-sectional study. BMC Public Health. 2011:11–21
|
| 31. | Pesa JA, Syre TR, Jones E. Psychosocial differences associated with body weight among female adolescents: the importance of body image. J Adolesc Health. 2000;26:330–337
|
| 32. | Place M, Reynolds J, Cousins A, O’Neill S. Developing a resilience package for vulnerable children. Child Adolesc Ment Health. 2002;7:162–167
|
| 33. | Reeves GM, Postolache TT, Snitker S. Childhood obesity and depression: connection between these growing problems in growing children. Int J Child Health Hum Dev. 2008;1:103–114
|
| 34. | Ricciardelli LA, McCabe MP. Self-esteem and negative affect as moderators of sociocultural influences on body dissatisfaction, strategies to decrease weight, and strategies to increase muscles among adolescent boys and girls. Sex Roles. 2001;44(3–4):189–207
|
| 35. | Salvy SJ, Coelho JS, Kieffer E, Epstein LH. Effects of social contexts on overweight and normal-weight children’s food intake. Physiol Behav. 2007;92:840–846
|
| 36. | Salvy SJ, Kieffer E, Epstein LH. Effects of social context on overweight and normal-weight children’s food selection. Eat Behav. 2008;9:190–196
|
| 37. | Schwimmer JB, Burwinkle TM, Varni JW. Health-related quality of life of severely obese children and adolescents. JAMA. 2003;289:1813–1819
|
| 38. | Shokaire Z Eating Disorder Test. 2000 Egyptian El Nahda Library
|
| 39. | Stice E, Presnell K, Spangler D. Risk factors for binge eating onset in adolescent girls: a 2-year prospective investigation. Health Psychol. 2002;21:131–138
|
| 40. | Tanofsky-Kraff M, Wilfley DE, Morgan CM, Yanovski SZ, Marmarosh C, Yanovski JA. Eating-disordered behaviors, body fat and psychopathology in overweight and normal-weight children. J Consult Clin Psychol. 2004;72:53–61
|
| 41. | Temple JL, Legierski CM, Giacomelli AM, Salvy SJ, Epstein LH. Overweight children find food more reinforcing and consume more energy than do nonoverweight children. Am J Clin Nutr. 2008;87:1121–1127
|
| 42. | Tershakovec AM, Weller SC, Gallagher PR. Obesity, school performance and behaviour of black, urban elementary school children. Int J Obes. 1994;18:323–327
|
| 43. | Wardle J, Cooke L. The impact obesity on psychological well-being. Best Pract Res Clin Endocrinol Metab. 2005;19:421–440
|
| 44. | Warschburger P. (Chronically ill children and adolescents: Psychological strains and coping tasks) 2000 Göttingen Hogrefe
|
| 45. | Weiss LG, Prifitera A, Roid G. The WISC-III and the fairness of predicting achievement across ethnic and gender groups. J Psychoeduc Assess. 1993;8:34–41
|
| 46. | Wilfley DE, Stein RI, Saelens BE, Mockus DS, Matt GE, Hayden-Wade HA, et al. Efficacy of maintenance treatment approaches for childhood overweight: a randomized controlled trial. JAMA. 2007;298:1661–1673
|
| 47. | Wilfley DE, Van Buren DJ, Theim KR, Stein RI, Saelens BE, Ezzet F, et al. The use of biosimulation in the design of a novel multilevel weight loss maintenance program for overweight children. Obesity. 2010;18(Suppl 1):S91–S98
|
| 48. | Williams J, Wake M, Hesketh K, Maher E, Waters E. Health-related quality of life of overweight and obese children. JAMA. 2005;293:70–76
|
| 49. | Young-Hyman D, Schlundt DG, Herman-Wenderoth L, Bozylinski K. Obesity, appearance and psychosocial adaptation in young African American children. J Pediatr Psychol. 2003;28:463–472
|
| 50. | Zeller MH, Saelens BE, Roehrig H, Kirk S, Daniels SR. Psychological adjustment of obese youth presenting for weight management treatment. Obes Res. 2004;12:1576–1586
|
[Table 1], [Table 2], [Table 3], [Table 4], [Table 5], [Table 6]
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