Barriers and facilitators of obesity management in families of youth with emotional and behavioral disorders

Abstract

While youth with emotional and behavioral disorders experience increased rates of obesity, few obesity interventions exist that are tailored to their needs. Qualitative methods were employed to elucidate obesity management practices in this population. In all, 56 participants (i.e. 21 youths with emotional and behavioral disorders, 20 caregivers of youth with emotional and behavioral disorders, and 15 mental health providers) were recruited from community mental health centers. Participants completed a demographic form and semi-structured interview regarding obesity-related behaviors. Barriers (e.g. psychiatric symptoms) and facilitators (e.g. social support) to obesity management were identified. These results highlight preferred intervention components for this unique population.

Keywords

barriers emotional and behavioral disorders interventions obesity youth

A recent estimate suggests that 31.8 percent of children and adolescents in the United States meet criteria for overweight or obesity (Ogden et al., 2012). Youth with emotional and behavioral disorders (e.g. depression, anxiety, attention deficit hyperactivity disorder [ADHD]) may be at even greater risk for obesity (e.g. Cook et al., 2014; Roberts and Duong, 2013). Furthermore, youth prescribed antipsychotic medication for these disorders are more likely to experience obesity-related disease than youth without a mental illness (Hammerman et al., 2008).

Existing data suggest that multiple factors may contribute to the increased rates of obesity in this population. For instance, depressive symptoms in adolescents have been associated with decreased physical activity and poorer diet quality (Castillo et al., 2014). In turn, reductions in physical activity and increases in sedentary behavior are associated with negative health outcomes in youth, such as cardiovascular disease and obesity (Tremblay et al., 2011). Additionally, the psychotropic medications prescribed to youth with emotional and behavioral disorders are associated with adverse health outcomes, such as weight gain (Correll et al., 2009) and diabetes (Hammerman et al., 2008).

Obesity is of particular concern because the condition is also associated with multiple physical and mental health issues among youth. For instance, obesity is associated with greater risk for diabetes (Bacha et al., 2010), pulmonary complications (Black et al., 2013), and decreased self-esteem (Cornette, 2011; Gray et al., 2009). Notably, research has demonstrated that the majority of overweight youth become obese adults (Singh et al., 2008); therefore, encouraging children and adolescents to adopt healthy lifestyle habits is crucial to the prevention of obesity in adulthood and its associated health risks.

However, few if any, obesity interventions have been developed for youth with emotional and behavioral disorders. Notably, research with typical youth (i.e. those without a mental health diagnosis) and adults with serious mental illness (SMI) has shown that obesity interventions can be effective in engendering weight loss (Bartels and Desilets, 2012; Oude Luttikhuis et al., 2009). For adults with SMI, lifestyle obesity interventions may be tailored to target psychiatric symptoms (e.g. repetition to improve knowledge retention; Daumit et al., 2013) and typically result in modest weight loss that can be maintained at follow-up (Bartels and Desilets, 2012; Daumit et al., 2013). Regarding obesity interventions for youth, the gold standard for treatment involves nutrition education, physical activity (e.g. increased physical activity, decreased sedentary activity), behavior modification, and family involvement (Caprio and Savoye, 2014; Oude Luttikhuis et al., 2009). Furthermore, the most effective interventions incorporate principles of self-monitoring, solution-focused coping, cognitive behavioral strategies, and relapse prevention (Caprio and Savoye, 2014). Lifestyle interventions (e.g. Bright Bodies program) incorporating these principles have been shown to result in weight loss and maintenance of weight loss in youth (Oude Luttikhuis et al., 2009; Savoye et al., 2011).

Traditional obesity interventions for youth may require modification to be effective for youth with emotional and behavioral disorders. Youth with these disorders may experience unique barriers to obesity management in addition to those encountered by youth without mental illness (e.g. poverty, provider barriers; Visram et al., 2013; Yarborough et al., 2012). For example, psychiatric symptoms and side-effects of psychotropic medications have been reported as barriers to obesity management in adults with SMI (Graham et al., 2013; McKibbin et al., 2014). Symptoms experienced by youth with emotional and behavioral disorders (e.g. anhedonia) may impair motivation to practice health behaviors (e.g. Scarapicchia et al., 2014). Moreover, adults with SMI report numerous barriers to accessing health care (Dickerson et al., 2003) and healthy food (Graham et al., 2013), as well as taste preferences for unhealthy food (Barre et al., 2011), which may generalize to families of youth with emotional and behavioral disorders. It has been recommended that health promotion interventions for adults with SMI incorporate the facilitators (e.g. social and provider support, symptom reduction) of health behaviors to improve outcomes (Roberts and Bailey, 2010). Consequently, tailoring obesity interventions to the unique experiences of youth with emotional and behavioral disorders may be necessary to achieve desirable outcomes.

As a first step toward the development of effective obesity interventions for youth with emotional and behavioral disorders, a rich understanding of the influences on obesity management is needed. We used qualitative methods to examine barriers and facilitators of obesity management from the perspectives of youth with emotional and behavioral disorders, their caregivers, and the community mental health providers who serve them.

Methods

Participants

We recruited a sample of 56 participants, including 21 youths, 20 parents or guardians, and 15 community mental health providers, from community mental health centers in the Rocky Mountain West. Youth eligibility criteria included the following: (1) ages 8–17 years; (2) diagnosis of an emotional and/or behavioral disorder; (3) prescription of at least one psychotropic medication; (4) status as overweight or obese or weight gain since beginning a psychotropic medication; (5) receipt of services in a regional community mental health center; and (6) ability to provide informed consent (e.g. ages 14–17 years) or assent (e.g. ages 8–13 years), and presence of a parent or guardian who was willing and able to provide informed consent.

Parent or guardian participants were required to meet the following criteria: (1) be at least 18 years of age; and (2) have a youth (ages 8–17 years) who met the above criteria. Community mental health providers were at least 18 years of age, had experience working with youth who met the above criteria, and were employed at a community mental health center. It was not required that both the parent or guardian and youth from a single family participate in the study.

Procedure

This study was approved by the university’s human subjects review committee. We recruited all participants from community mental health centers in the Rocky Mountain West through study advertisements and provider referral. Brochures and releases of information that adhered to Health Insurance Portability and Accountability Act (HIPAA) regulations were given to mental health providers to review with families during their visits. These providers alerted families to the study, and either provided the parent with study contact information or gave the opportunity for the parent to sign a release of information. Following receipt of a signed release, providers shared the demographic and clinical information (e.g. age and diagnosis) of interested families with research staff to confirm that inclusion criteria were met. Study staff then contacted families who met criteria to explain the study and schedule a study visit. All study visits were completed in the participants’ homes or at their community mental health center. The study purpose was reviewed at the study visit, and participants were invited to provide consent or assent as appropriate. Participants then provided demographic information via paper and pencil questionnaires developed for the study. Finally, participants completed a semi-structured interview to assess barriers and facilitators to obesity management. The interviews lasted approximately 1 hour for parents and providers and 30 minutes for youth. Participants were compensated for their time (i.e. US$30 for providers, US$40 for parents, and US$15 for youth).

Qualitative interview

The semi-structured interviews consisted of seven questions to elicit expansion of participants’ responses and obtain additional data as needed (e.g. Merriam, 1998). Sample questions include (1) “Tell me about your eating” and (2) “How do you feel about your physical health.” Parents and youth answered questions regarding personal and family habits related to mental and physical health, and providers answered questions regarding factors that influence families’ engagement in obesity management practices. Participant responses during the interview were audio-recorded and transcribed verbatim.

Descriptive measures

Parents completed demographic and developmental history questionnaires that were developed for the study. The questionnaires included multiple choice and short answer questions and assessed information such as socioeconomic status, youth diagnosis, age of onset, and developmental delays. Providers also completed a demographic form developed for the study which assessed factors such as credentials, role in the community mental health center, and years of practice with youth with emotional and/or behavioral disorders. These data were used to provide context to the qualitative responses and no other quantitative measures were administered.

Data analysis

Members of the research team conducted descriptive analyses on study sample demographic characteristics with SPSS, version 21. For the qualitative data analysis, the coding team (KAB, CLM, KAK) followed a three-stage procedure described by Corbin and Strauss (2008). First, we used open-ended coding in an initial review of responses to apply conceptual labels (i.e. codes) to responses with similar meaning and organized similar responses into larger categories (Corbin and Strauss, 2008). Second, we compared and combined categories with similar meaning into broader themes (axial coding; Corbin and Strauss, 2008). Finally, we identified core themes that appeared across the majority of interviews (selective coding; Corbin and Strauss, 2008). We organized the codes in a codebook, which were edited as necessary (Guest and MacQueen, 2008). Consistent with common practice in qualitative research, we conducted interviews until saturation (i.e. the point at which no additional themes emerge from the data) was reached (Glaser and Strauss, 1967). To determine the point at which saturation was achieved, we created a saturation table to track the presence or absence of a theme in each interview (Brod et al., 2009; Kerr et al., 2010). Following Guest and MacQueen (2008), inter-rater reliability was assessed via a percent-agreement approach, in which an overall percent-agreement between coders ≥85 percent was considered to be acceptable. The coding team independently coded text from randomly selected pages of interviews and determined the consistency with which identical codes and themes were identified. Discrepancies were discussed and revisions to the codebook were made when necessary. Final percent-agreement was 86.67 percent.

Results

Demographics

In all, 21 youths, 20 parents/guardians, and 15 providers consented and participated in the study. Demographic data for two parents and youths were not collected, as these youths participated without their parents. One parent declined to answer demographic questions, aside from reporting age and gender. Youth ranged in age from 8 to 17 years (M = 12.67, standard deviation (SD) = 3.12) and were primarily European American (n = 13, 65.00%) and male (n = 15, 71.40%). The majority of youth (n = 15; 71.43%) had more than one diagnosis, with the most commonly reported diagnoses of ADHD (n = 9, 42.90%) and mood disorder not otherwise specified (NOS; n = 9, 42.90%). The average age of onset was approximately 7 years (M = 7.68, SD = 3.07). Parents did not provide age of onset data for seven youths. In all, 18 (85.70%) youths were prescribed a second-generation antipsychotic medication. Parents ranged in age from 24 to 56 years (M = 39.25, SD = 8.83). The majority were European American (n = 16, 80.00%), female (n = 18, 90.00%), and married (n = 12, 63.20%). One parent did not provide information regarding race/ethnicity or marital status. Most parents were unemployed at the time of the interview (n = 11, 64.70%). Three parents did not respond to the employment question. Nine parents (52.9%) reported having a mental health diagnosis, of which post-traumatic stress disorder (n = 7, 77.80%) was the most common diagnosis endorsed. Three parents declined to answer this question.

The majority of providers were European American (n = 11, 73.30%), female (n = 13, 86.70%), and had obtained a graduate degree (n = 11; 73.30%). Providers represented the professions of psychology (n = 1; 6.70%), nursing (n = 3; 20.00%), medicine (n = 3; 20.00%), clinical social work (n = 3; 20.00%), and other mental health-related professions, such as case workers (n = 5; 33.30%). Their years of experience working with youth ranged from 1.50 to 25.00 years (M = 12.67, SD = 8.67).

Thematic analysis

Parents and youth provided definitions of health and identified factors that facilitate or inhibit engagement in obesity-related health behaviors (e.g. nutritious diet and physical activity). Providers identified factors they believed were influential in families’ management of obesity. They also identified barriers and facilitators to discussing weight and lifestyle behaviors with families during therapy and medication appointments.

Definition of health

While youth were able to identify aspects of what it means to be healthy, their definitions were often simple and incomplete. Simple definitions of what it means to be healthy included statements such as being “skinny” (100010 Ca). Incomplete definitions of what it means to be healthy included statements where youth showed broad knowledge of healthy lifestyle concepts (e.g. diet and exercise), but provided inaccurate information regarding components of and recommendations for a healthy lifestyle or did not mention components of overall health and wellness (e.g. inclusion of mental health). For instance, youth generally had basic knowledge of the food pyramid or “MyPlate” (United States Department of Agriculture (USDA), 2011), but misjudged unhealthy foods for healthy foods (e.g. “filet mignon” (100008C) as a healthy protein) and underestimated recommended levels of physical activity for youth.

Although youth definitions of health comprised mainly of aspects of physical health, parents identified mental health as a significant component of overall health and wellness for their children. Most parents remarked that mental health was their greatest concern regarding their children. For instance, one parent of a 17 year-old-boy added, “I am more worried about his mental health, more mental health than anything” (275P). Parents reported concerns about their child’s future, including school performance, behavioral and emotional stability, and social skills. Providers also believed mental health was the primary concern for youth, reflected by prioritization of mental health symptoms during appointments. However, several parents acknowledged growing concern about their child’s physical health, following the development of psychotropic medication-related health problems (e.g. pre-diabetes, fatty liver disease, weight gain). Few parents reported physical health as their priority concern for their children. The parents who prioritized physical health reportedly only chose to do so once their childrens’ mental health was stabilized. One mother of a boy with mood disorder NOS, oppositional defiant disorder, and an anxiety disorder stated, “… we have his mental health pretty stable, so it’s the physical. … Gotta take care of the important one first” (271P).

Barriers

Participants identified a set of common (e.g. poverty) and unique (e.g. psychiatric symptoms) barriers to engaging in healthy choices and effectively managing mental health symptoms.

Mental health symptoms

Parents, youth, and providers discussed the significant impact of mental health symptoms (e.g. oppositionality, depression, aggression) on the physical health of youth. The mother of a 12-year-old girl provided a powerful example of the difficulty she experiences setting limits on her daughter’s food consumption, due to her aggressive response: “… I tried putting rules down … that would start the physical aggression … So I have decided that for my sanity and safety that ya know what, I’m not going to stand in the way anymore” (259Pa). Moreover, parents and youth noted that depressive symptoms (e.g. anhedonia, fatigue) impact diet and physical activity. They reported that when depressed, youth are more likely to consume “comfort foods” and engage in sedentary activities, such as screen time. Interestingly, providers also discussed the impact of parental mental health and parenting stress on the physical health of youth. For instance, providers reported that caregivers with personal mental health concerns were more likely to use pre-prepared foods or allowed youth to purchase convenience store foods rather than cooking healthy meals. Providers also acknowledged that stress and fatigue from caring for a child with emotional and/or behavioral disorder can be associated with difficulty prioritizing physical health needs.

In addition to psychiatric symptoms, participants reported that psychotropic medications had contributed to changes in youth weight and appetite; these changes were the most commonly reported side-effects of psychotropics. One mother of a 17-year-old boy remarked that her son had gained 44 pounds in the past year, following initiation of psychotropic medication. Reportedly, youth outcomes include both appetite and weight increases (e.g. with antipsychotics) and decreases (e.g. with stimulants) depending upon the type of psychotropic medication taken. Despite attempts to control types and portions of food consumed, several youth reported experiencing weight gain following prescription of psychotropic medication (e.g. “… I’m on new medication … and, even if I eat less, eat healthier … [I] just gain more weight” (270C)). Other youth noted that food portions and cravings for sweet and salty foods increased with use of psychotropics. For instance, the mother of a girl with ADHD, mood disorder NOS, and oppositional defiant disorder noted, “… she just started sneaking sweets … I would find wrappers under her bed or a new container of Oreos would be gone the next morning. … in just a few months she really ballooned up” (100007P). Notably, families continued to use psychotropic medications, because they believed the benefits (e.g. symptom reduction) outweighed the negative health consequences.

Taste and texture

Many parents reported their children’s food preferences made it difficult to encourage consumption of healthy meals. Specifically, parents reported their children were picky eaters with aversions to the taste and textures of some foods. Parents noted their children avoided certain foods, ate other foods only if prepared in a particular manner, or attempted to mask the taste and texture of some foods with unhealthy additives (e.g. salad dressing). While these aversions were not limited to fruits and vegetables, they often included potentially healthy dietary choices, such as chicken, vegetables, and fruits. One father commented on his daughter’s aversion to certain textures: “… she’s real picky. … I think it’s more of a texture thing … she’ll put food in her mouth and she’ll … sorta roll it over with her tongue” (259Pb). Youth echoed parents’ perceptions, making statements such as, “… I think they’re [vegetables] gross … when I try to eat it [vegetable] (vomiting sound)” (100004C).

Access

Participants reported several factors that increase the difficulty of accessing healthy foods and physical activity opportunities, including poverty, transportation, and time. For instance, the high cost of fresh fruits and vegetables reportedly made it difficult for parents to keep those foods consistently available in their home: “… it’s hard for us to keep vegetables … fruits in the house because they’re so expensive” (260P). Due to lack of finances and the scarcity of local grocery stores, providers noted families often grocery shopped at convenience stores. One provider commented,

… a lot of kids, its access to … running down to 7-Eleven and getting … giant sodas and a bag of chips. And … that’s what … parents have said, “run down to the store and get yourself a snack,” as opposed to having access to more of the healthy foods. (262Pr)

Parents in particular noted that poverty also negatively impacted the ability of youth to engage in organized physical activity through school athletic teams and/or attend local gyms or recreation centers. Parents and providers further detailed that lack of transportation prevented families from grocery shopping, attending mental health appointments, and participating in recreational activities away from the home. One provider illustrated a family’s struggles with transportation, “… to go to the grocery store they have to get on the bus, with five children … it is really a difficult thing. It can take them all day to get their groceries …” (256Pr). Several families, parents in particular, also noted a lack of time to prepare healthy meals and engage in physical activity. Often, lack of time increased consumption of pre-packaged foods and high-calorie foods from fast food restaurants, as well as decreased desire to be physically active.

Clinician factors

Providers described factors that prevent them from discussing health-related topics in session. Nearly all providers reported a lack of time during sessions, as well as a lack of staff in general, to work on improving obesity management in caregivers and youth. Providers found it difficult to balance discussing mental and physical health issues during session: “… it is tough, because I don’t prioritize it [discussion of healthy lifestyle behaviors] ‘cause there’s so much, you know, I’m dealing with all the other stuff too …” (267Pr). Furthermore, several providers reported fears of offending their clients by addressing weight. For instance, one provider reported a fear of sounding judgmental and as though she was “lecturing” clients (263Pr), while another provider identified a concern of sounding “arrogant” because she did not experience the same degree of difficulty in affording fresh produce as her clients (256Pr).

Facilitators

Although families experience significant barriers to managing obesity, they possess strengths that may allow them to overcome some, if not all, of those barriers.

Social support

Youth were more likely to make healthy diet and activity choices when they received support for and modeling of healthy choices from friends and/or family members. Several parents remarked that they or other family members encouraged their child to be physically active or accompanied their child when s/he engaged in physical activity. Other youth and parents reported that family provided support for healthy lifestyle behaviors by modeling healthy choices and problem-solving skills to make healthier snack choices, as well as teaching youth to cook and evaluate nutrition labels. Parents reported that providers also offered support, for example, by engaging with parents in problem-solving regarding nutrition and grocery shopping on a budget. Several providers used weekly sessions with youth as an opportunity to engage them in physical activity. For example, one licensed clinical social worker stated, “… I try to incorporate some sort of exercise … 35, 40 minutes, we’re gonna be outside playing soccer or hitting a baseball …” (262Pr). The provision of education, problem-solving skills, and access to exercise and healthy snacks during sessions gave families the opportunity to have at least some contact with healthy behaviors during the week.

Access

When families were able to access healthy diet and activity choices, they were more likely to consume fruits and vegetables and decrease sedentary behaviors. For instance, providers reported the food bank at their local community mental health center provided many families with fresh fruits and vegetables. Additionally, youth were more likely to make healthy lifestyle choices when they had access to fruits and vegetables, sports equipment (e.g. basketball hoops, pools), affordable athletic programs, and parks and playgrounds. Furthermore, when parents limited the “junk food” available in the home, they created an “out of sight, out of mind” mentality and increased consumption of fruits and vegetables: “… my parents try to keep the food … that’s hanging around the house relatively healthy” (100013C). Finally, parents who problem-solved access-related barriers increased the likelihood their child would make healthy diet and activity choices.

Clinician factors

Providers also identified factors that increase the likelihood they will address physical health with their clients. They overwhelmingly reported being more comfortable discussing obesity management with clients when overall health and wellness was part of the explicit treatment goal. Making the discussion of this otherwise “touchy subject” a standard and expected goal of treatment eased clinician concerns of offending their clients, and allowed for frank discussions of weight and problem-solving weight-related behaviors. For instance, one provider commented, “… I do it [discuss weight-related issues] every time, so … families know that it’s gonna happen” (254Pr). Finally, several providers reported collaboration with other medical professionals allowed them to focus on mental health, while still addressing the diet and exercise-related needs of their clients: “… I coordinate with our medical provider … she addresses the health piece … I try to address more of the emotional eating that comes in …” (267Pr).

Discussion

This study is among the first todirectly assess the factors that influence obesity management in families of youth with emotional and behavioral disorders. Several important themes were identified which suggest the need for a multilevel intervention. Parents and youth differed in their definitions of health, such that parents may prioritize mental health while youth prioritize weight. Additionally, parents and youth provided narrow and incomplete definitions of what it means to be healthy (e.g. “skinny”), suggesting that they may lack the knowledge of how to improve overall wellness. Parents, youth, and providers acknowledged other person- and environment-related barriers to obesity management, including psychiatric symptoms (e.g. anhedonia), medication side-effects, and lack of access. Alternatively, many participants noted that having a support system for healthy behaviors and access to healthy foods and activities facilitated obesity management. These findings are largely consistent with prior research on factors that influence obesity management in adults with SMI (e.g. Barre et al., 2011; Roberts and Bailey, 2010).

Similar to Yarborough et al. (2012), several providers noted that they were uncomfortable discussing or lacked time in session to address weight-related concerns with clients. However, consistent with findings from McKibbin et al. (2014), multiple providers in this sample described means to discuss weight in session, by playing games, providing healthy snacks, and incorporating health into the mental health treatment plan. These findings suggest that many mental health providers may benefit from education and training on how to intervene with weight-related concerns in their clients (Soundy et al., 2007).

These results contribute to the literature by highlighting potentially important targets of intervention for youth with emotional and behavioral disorders and weight-related concerns. For instance, both common (e.g. poverty) and unique (e.g. psychiatric symptoms) barriers to obesity management were identified, and targeting these specific issues may increase the acceptability, accessibility, and efficacy of a lifestyle obesity intervention for this group. For example, to address families’ lack of knowledge about health and differential prioritization of components of health, a tailored obesity intervention should include nutrition education (Caprio and Savoye, 2014) and education regarding the bi-directional relationship between mental and physical health (Da Silva et al., 2012). Furthermore, families should teach the skills necessary to manage mental health (e.g. reward systems) in conjunction with physical health (e.g. nutrition, exercise). Utilizing cognitive and behavioral techniques (e.g. motivational interviewing, parent-training, exercise-related behavioral activation; Channon et al., 2007; Epstein et al., 1981; Hoek et al., 2011; Kaslow et al., 2012) relevant to improving both mental and physical health may fit within the framework of empirically supported treatment principles for both obesity and emotional and behavioral disorders (Caprio and Savoye, 2014; Weisz and Kazdin, 2010). Each intervention component should include repetition of concepts and skills (Daumit et al., 2013), provide incentives to increase motivation (e.g. McKibbin et al., 2014), and implement a behavior management system to target psychiatric symptoms. Finally, the program should utilize families’ strengths within a solution-focused framework (Caprio and Savoye, 2014) to empower families. For example, families could create a “buddy system” with other group members to problem-solve barriers and support the continued use of adaptive mental and physical health behaviors (e.g. McKibbin et al., 2014; Soundy et al., 2007).

Although it has been suggested that obesity management programs be incorporated into community mental health (Richardson et al., 2005), results from this study suggest that providers may first require psychoeducation regarding how to effectively discuss and monitor the physical health of their clients. Hetrick et al. (2010) have developed an intervention to increase metabolic monitoring by psychiatrists treating young adults with first episode psychosis. The intervention incorporates behavior change techniques such as didactic training, consistent audits and feedback, and provision of equipment necessary for monitoring (Hetrick et al., 2010). An intervention of this type may be a cost-effective way to target provider beliefs and practices regarding weight monitoring within a community mental health setting. In sum, results from this study highlight the importance of developing a multilevel obesity intervention that addresses change at system (e.g. setting institutional priorities for overall wellness), provider (e.g. incorporation of health behaviors into overall treatment goals), parent (e.g. skills to engage the family in behavior change), and youth (e.g. decreased psychiatric symptoms and increased engagement in health behaviors) levels.

These results should be interpreted within the context of the study’s limitations. The factors that influence obesity management in these families may not generalize to families with other sociodemographic and treatment characteristics. Furthermore, the barriers and facilitators to discussing health behaviors reported by providers may not generalize to providers working in other settings or with other populations. As these families were referred to the study by their mental health provider, they may be more involved in treatment and receive additional supports than the general population of youth with emotional and behavioral disorders. Finally, perspectives on obesity management were obtained via self-report, which may be susceptible to biases in recall and reporting, as well as influenced by whether another family member was present during the interview.

In summary, the findings from this study are a first step toward developing an obesity intervention tailored to the unique needs and strengths of this population. Further research is needed to investigate whether incorporating these factors into an obesity intervention is acceptable and feasible for use with youth with emotional and behavioral disorders. Future research should then assess whether such an intervention leads to improved mental and physical health outcomes for this group.

Footnotes

Acknowledgements

The authors would like to thank the Mental Health Center of Denver staff, who helped to coordinate data collection, as well as those staff who also participated in the study.

Declaration of conflicting interests

The author(s) received no financial support for the research, authorship, and/or publication of this article.

Funding

The author(s) disclosed receipt of the following financial support for the research, authorship, and/or publication of this article: This work was supported by the National Center for Research Resources (5P20RR016474-12) and the National Institute of General Medical Sciences from the National Institute of Health (8P20GM103432-12).

References

Bacha

Lee

Gungor

et al . (2010) From pre-diabetes to type 2 diabetes in obese youth: Pathophysiological characteristics along the spectrum of glucose dysregulation. Diabetes Care 33(10): 2225–2231.

Barre

Ferron

Davis

et al . (2011) Health eating in persons with serious mental illnesses: Understanding and barriers. Psychiatric Rehabilitation Journal 34(4): 304–310.

Bartels

Desilets

(2012) Health Promotion Programs for People with Serious Mental Illness (prepared by the Dartmouth health promotion research team). Washington, DC: SAMHSA-HRSA Center for Integrated Health Solutions.

Black

Zhou

Takayanagi

et al . (2013) Increased asthma risk and asthma-related health care complications associated with childhood obesity. American Journal of Epidemiology 178(7): 1120–1128.

Brod

Tesler

Christensen

(2009) Qualitative research and content validity: Developing best practices based on science and experience. Quality of Life Research 18(9): 1263–1278.

Caprio

Savoye

(2014) Treatment of the obese child or adolescent. In: Kushner

Bessesen

(eds) Treatment of the Obese Patient. New York: Springer, pp. 305–322.

Castillo

Francis

Wylie-Rosett

et al . (2014) Depressive symptoms are associated with excess weight and unhealthier lifestyle behaviors in urban adolescents. Childhood Obesity 10(5): 400–407.

Channon

Huws-Thomas

Rollnick

et al . (2007) A multicenter randomized controlled trial of motivational interviewing in teenagers with diabetes. Diabetes Care 30(6): 1390–1395.

Cook

Heinrich

(2014) Obesity, physical activity, and sedentary behavior of youth with learning disabilities and ADHD. Journal of Learning Disabilities 48(6): 563–576.

10.

Corbin

Strauss

(2008) Basics of Qualitative Research (3rd edn). Los Angeles, CA: SAGE.

11.

Cornette

(2011) The emotional impact of obesity on children. In: Bagchi

(ed.) Global Perspectives on Childhood Obesity: Current Status, Consequences, and Prevention. New York: Elsevier, pp. 257–264.

12.

Correll

Manu

Olshanskiy

et al . (2009) Cardiometabolic risk of second-generation antipsychotic medications during first time use in children and adolescents. JAMA: Journal of the American Medical Association 302(16): 1765–1773.

13.

Da Silva

Singh-Manoux

Brunner

et al . (2012) Bidirectional association between physical activity and symptoms of anxiety and depression: The Whitehall II study. European Journal of Epidemiology 27: 537–546.

14.

Daumit

Dickerson

Wang

et al . (2013) A behavioral weight-loss intervention in persons with serious mental illness. New England Journal of Medicine 368(17): 1594–1602.

15.

Dickerson

McNary

Brown

et al . (2003) Somatic healthcare utilization among adults with serious mental illness who are receiving community psychiatric services. Medical Care 41(4): 560–570.

16.

Epstein

Wing

Koeske

et al . (1981) Child and parent weight loss in family-based behavior modification programs. Journal of Consulting and Clinical Psychology 49(5): 674–685.

17.

Glaser

Strauss

(1967) The Discovery of Grounded Theory: Strategies for Qualitative Research. London: Aldine de Gruyter.

18.

Graham

Griffiths

Tilloston

et al . (2013) Healthy living? By whose standards? Engaging mental health service recipients to understand their perspectives of, and barriers to, healthy living. Psychiatric Rehabilitation Journal 36(3): 215–218.

19.

Gray

Kahhan

Janicke

(2009) Peer victimization and pediatric obesity: A review of the literature. Psychology in the Schools 46(8): 720–727.

20.

Guest

MacQueen

(2008) Handbook of Team-Based Qualitative Research. Plymouth: Altamira Press.

21.

Hammerman

Dreiher

Klan

et al . (2008) Antipsychotics and diabetes: An age related association. The Annals of Pharmacotherapy 24: 1316–1322.

22.

Hetrick

Álvarez-Jiménez

Parker

et al . (2010) Promoting physical health in youth mental health services: Ensuring routine monitoring of weight and metabolic indices in a first episode psychosis clinic. Australasian Psychiatry 18(5): 451–455.

23.

Hoek

Marko

Fogel

et al . (2011) Randomized controlled trial of primary care physician motivational interviewing versus brief advice to engage adolescents with an Internet-based depression prevention intervention: 6-month outcomes and predictors of improvement. Translational Research 158(6): 312–325.

24.

Kaslow

Broth

Smith

et al . (2012) Family-based interventions for child and adolescent disorders. Journal of Marital and Family Therapy 38(1): 82–100.

25.

Kerr

Nixon

Wild

(2010) Assessing and demonstrating data saturation in qualitative inquiry supporting patient-reported outcomes research. Expert Review of Pharmacoeconomics & Outcomes Research 10(3): 269–281.

26.

McKibbin

Kitchen

Wykes

et al . (2014) Barriers and facilitators of a healthy lifestyle among persons with serious and persistent mental illness: Perspectives of community mental health providers. Community Mental Health Journal 50: 566–576.

27.

Merriam

(1998) Qualitative Research and Case Study Applications in Education: Revised and Expanded from “Case Study Research in Education.” San Francisco, CA: Jossey-Bass Publishers.

28.

Ogden

Carroll

Kit

et al . (2012) Prevalence of obesity and trends in body mass index among US children and adolescents, 1999–2000. JAMA: Journal of the American Medical Association 307(5): 483–490.

29.

Oude Luttikhuis

Baur

Jansen

et al . (2009) Interventions for treating obesity in children. Cochrane Database of Systematic Reviews 1(1): 1–163.

30.

Richardson

Faulkner

McDevitt

et al . (2005) Integrating physical activity into mental health services for persons with serious mental illness. Psychiatric Services 56(3): 324–331.

31.

Roberts

Duong

(2013) Obese youths are not more likely to become depressed, but depressed youths are more likely to become obese. Psychological Medicine 43(10): 2143–2151.

32.

Roberts

Bailey

(2010) Incentives and barriers to lifestyle interventions for people with severe mental illness: A narrative synthesis of quantitative, qualitative and mixed methods studies. Journal of Advanced Nursing 67(4): 690–708.

33.

Savoye

Nowicka

Shaw

et al . (2011) Long-term results of an obesity program in an ethnically diverse pediatric population. Pediatrics 127(3): 402–410.

34.

Scarapicchia

TMF

Sabiston

O’Loughlin

et al . (2014) Physical activity motivation mediates the association between depression symptoms and moderate-to-vigorous physical activity. Preventive Medicine 66: 45–48.

35.

Singh

Mulder

Twisk

et al . (2008) Tracking of childhood overweight into adulthood: A systematic review of the literature. Obesity Reviews 9(5): 474–488.

36.

Soundy

Faulkner

Taylor

(2007) Exploring variability and perceptions of lifestyle physical activity among individuals with severe and enduring mental health problems: A qualitative study. Journal of Mental Health 16(4): 493–503.

37.

Tremblay

LeBlanc

Kho

et al . (2011) Systematic review of sedentary behavior and health indicators in school-aged children and youth. International Journal of Behavioral Nutrition and Physical Activity 8(1): 1–22.

38.

United States Department of Agriculture (USDA) (2011) USDA’s MyPlate.gov—What foods are in the fruit group? Available at: http://www.choosemyplate.gov/

39.

Visram

Hall

Geddes

(2013) Getting the balance right: Qualitative evaluation of a holistic weight management intervention to address childhood obesity. Journal of Public Health 35(2): 246–254.

40.

Weisz

Kazdin

(2010) Evidence-Based Psychotherapies for Children and Adolescents (2nd edn). New York: Guilford Press.

41.

Yarborough

DeBar

et al . (2012) Responding to pediatric providers’ perceived barriers to adolescent weight management. Clinical Pediatrics 51(11): 10563–11070.