Raising child mental health concerns with parents of children with higher weight

Who is this resource for?

This resource is for health practitioners working with children experiencing higher weight and their families. This includes:

• general practitioners
• paediatricians
• psychologists
• dietitians
• exercise physiologists/physiotherapists.

This resource may be particularly helpful in cases where the practitioner has identified a potential mental health concern, but is unsure how to raise it with the family.

Why is this information important?

Research shows parents have a strong influence on their children’s physical and psychological wellbeing. In particular, parents’ weight-related beliefs, attitudes and behaviours, regardless of their child’s actual weight, can affect children’s wellbeing (Robinson, Daly & Sutin, 2020). Working with parents to prevent or intervene early in mental health issues with a child experiencing higher weight can make a significant difference to the child’s long-term outcomes.

Further to this, healthcare professionals can be a source of weight bias and stigma (Pont et al., 2017), with health professionals themselves reporting negative attitudes towards higher weight patients (Mikhailovich & Morrison, 2007). Healthcare workers may also feel reluctant to discuss weight due to concerns about offending or stigmatising parents. It is essential that healthcare professionals understand how to work with families in ways that build trust, engagement and motivation for change, while strengthening parents’ efforts to support their children.

Some of the key issues related to weight and mental health in childhood that contribute to the need for this resource are:

• Children with higher weight are at greater risk of negative mental health and wellbeing outcomes than children in the ‘normal’ weight range (as defined by body mass index [BMI]).
• Weight stigma (e.g. bullying and teasing) and concerns about size and shape explain much of the relationship between higher weight and negative mental health and wellbeing outcomes.
• The language used to talk about weight can contribute to children’s feelings of shame and stigma.
• A focus on weight and weight loss can negatively affect children’s wellbeing and undermine efforts to improve their physical and mental health.
• Whole-of-family interventions that focus on reducing stigma and shame and promoting healthy lifestyles, body image and body satisfaction can improve the wellbeing of children with higher weight.

Further information on the connections between higher weight and mental health and wellbeing, along with practice considerations, can be found in the practice paper, Higher weight and mental health and wellbeing in childhood. It is recommended you read this paper prior to raising concerns with parents and families.

On this page:

• Allow enough time
• Consider your own beliefs, attitudes and knowledge about higher weight in children
• Use non-stigmatising language
• Consider who could be part of the discussion

The steps outlined in this resource are founded on family partnership principles, strengths-based practice, adult capacity building and motivational interviewing strategies. They focus on collaborating with families in a way that builds their motivation to address concerns about their child’s mental health and wellbeing.

By following this approach, you can:

• raise concerns with parents in a way that supports engagement with the family
• see parents as active partners in understanding and addressing any concerns
• walk alongside families, learning with them about how to address a concern.

Before raising concerns

Parents have reported wanting to talk about their child’s higher weight, if approached in a way that is not judgemental or stigmatising and supports their efforts and their child’s wellbeing.

To ensure that families feel supported, consider the following before raising concerns:

Allow enough time

Understand that both weight and mental health can be sensitive issues and be prepared for a wide range of parental responses, including strong emotions and denial of the concerns (Mikhailovich & Morrison, 2007; Provvidenza et al, 2017). You may need a staged approach over multiple sessions to build trust and engagement with a family. GPs might consider the need for a few longer consultations to build rapport with the family and make it easier to discuss these issues. It may help to offer parents a session on their own or through telehealth, to make it easier to discuss any concerns openly. When discussing sensitive issues, allowing time for questions and providing written resources for the family to take away can help (Mikhailovich & Morrison, 2007). If you have limited time, consider the key areas of need and prioritise and plan for the session accordingly.

Consider your own beliefs, attitudes and knowledge about higher weight in children

Recognise that the causes of higher weight are complex with biological, behavioural and environmental factors all contributing (AIHW, 2020b; Russell-Mayhew, McVey, Bardick & Ireland, 2012). Take time to reflect on your own attitudes and beliefs about weight, what may be influencing them (e.g. culture, the media) and how these beliefs or attitudes may affect your work with families (Provvidenza et al., 2017). Then adjust your practice accordingly.

Demonstrating non-biased attitudes and language and taking a non-judgmental approach will help build warm and trusting relationships with families (Bradbury et al., 2018; Mikhailovich & Morrison, 2007; Pont et al., 2017; Small & Aplasca, 2016). Showing concern, rather than professional detachment, and being confident and caring have been found to help when discussing potentially difficult topics with parents (Mikhailovich & Morrison, 2007).

Use non-stigmatising language

The language we use can contribute to poorer outcomes for children. Parents of children with higher weight may feel shame or a sense of guilt over their child’s weight. Acknowledging the societal factors involved in weight and emphasising the child’s strengths can help (Mikhailovich & Morrison, 2007).

Where appropriate, focus on health and healthy lifestyles rather than weight. If you do need to talk about weight, work with families to understand the language they find acceptable and feel comfortable with (Mihrshahi et al., 2018; Pont et al., 2017). Families may prefer words such as ‘weight’ or ‘body mass index’ rather than ‘obese’ or other potentially stigmatising terms (Pont et al., 2017).

Role modelling supportive, non-judgemental and non-biased attitudes and language with children is also critical (Pont et al., 2017). When we demonstrate appropriate responses, parents are more likely to adopt the same supportive, non-biased attitudes and language with their children.

Consider who could be part of the discussion

Ask the family’s permission to engage in any conversation about higher weight and mental health and consult with them about who should take part. Depending on your professional role, it can be helpful to consider (where possible) how others might support the process. It may just be a conversation with parents about how others could be involved, particularly extended family who provide care for the child. Other family members and friends can be a sustainable source of support for parents. They can help sustain interventions or strategies that are undertaken to achieve the family’s goals.

If developmentally and age appropriate, ask children if they would like to be included in the conversation, too.

Note: The examples provided throughout this resource focus on issues that have been linked to mental health and wellbeing and higher weight, such as:

• relationships with family and peers
• body weight and shape concerns
• parents’ weight-related beliefs and behaviours; and
• underlying conditions (e.g. depression, autism spectrum disorder).

The examples model the use of non-stigmatising language and focus on health and healthy lifestyle rather than weight. Further practice scenarios exploring the connections between higher weight and children’s wellbeing are provided in the online course, Supporting the mental health of children with higher weight.

On this page:

• Using OARS (Open-ended questions, Affirmations, Reflections and Summaries)
• Exploring the family’s strengths, skills and strategies
• Exploring parents’ views on their child’s mental health
• Exploring the family’s understandings, values, beliefs and circumstances

There will be times when you have identified a concern about a child’s mental health in the context of higher weight, but do not know enough about the situation. It can be helpful to ask some questions to learn more about the child, their family, and how things are going for them – including what’s working well and what they would like to be different. Exploring parents’ beliefs, attitudes and specific circumstances can also help. the OARS techniques can help you to gather information while maintaining engagement throughout your work with parents and families.

A detailed discussion of exploring families’ needs and circumstances and raising mental health concerns with parents can be found in the Emerging Minds practice paper, Exploring child mental health concerns with parents.

Your aim here is to explore factors related to the mental health and wellbeing of children with higher weight (e.g. peer relationships, body weight and shape concerns, parent weight-related attitudes and behaviours, other underlying conditions), in order to identify areas of concern for further exploration. It is important to note that not all children with higher weight experience poor mental health.

You are interested in exploring:

• the family’s strengths, including their skills and strategies to cope with challenges and stressors
• the parents’ views on their child’s general mental health and wellbeing; and

the family’s values, beliefs and circumstances, including health-related behaviours that may affect the child’s wellbeing, as well as their knowledge and understanding of the connections between weight and mental health.

Exploring the family’s strengths, skills and strategies

Exploring a family’s strengths and skills can give you an indication of how the family is currently coping. It can also provide useful information on what is working well and how the family may address potential child wellbeing concerns. Beginning with a focus on the family’s strengths can also instil hope in the process and promote engagement and motivation for change.

Throughout the duration of your work, a key task is to identify and build on the family’s existing strengths and skills and use these to develop new ones. Sharing these observations has a big impact, especially as parents rarely receive positive messages about how they are parenting. Further, in the context of higher weight parents may have experienced stigma and shame and may have had negative experiences with health professionals.

You might say something like:

• ‘It’s fantastic to see how, through your ongoing encouragement, you were able to support Sally to return to dance lessons. What do you think helped you achieve this?’
• ‘It’s wonderful to hear about your bike ride with River. I wonder how you were able to get him to join you for a ride on the weekend. What do you think helped him get off his devices and out with you?’
• ‘We’ve identified quite a few things that are working well for you and your family. From what we’ve discussed so far, what do you think you might draw on to help you increase everyone’s fruit and vegetable intake?’

Exploring parents’ views on their child’s mental health

When exploring parents’ views on their child’s general mental health and wellbeing, you are interested in:

• the child’s relationships with their parent/s, other family members, peers and teachers
• routines and home life
• the child’s interests and activities and engagement with these
• other conditions that may be affecting the child’s weight and wellbeing, such as mental health concerns, disability or neurodevelopmental disorders.

There are many questions you could ask, and what you ask will depend on what you already know about the family. Here are some ideas to get the conversation started:

• ‘How would you describe [child’s name] to someone who doesn’t know them? What would you say are their strengths?’
• ‘How does your child talk about themselves? How do you think they would describe themselves to someone who doesn’t know them?’
• ‘What activities does your child enjoy doing? When and who do they do these with?’
• ‘How does your child feel about school? Can you tell me what a day at school might look like for your child?’
• ‘What does your child do during recess and lunch at school? Who are they spending time with? Have you spoken to [child name’s] teacher about how she’s doing?’
• What’s it like for your child when your family or friends come over?
• You mentioned that [child’s name] has been recently diagnosed with ASD. Can you tell me a little more about that? [E.g. medications, eating behaviours, physical activities]’

Exploring the family’s understandings, values, beliefs and circumstances

The relationship between weight and psychological wellbeing is complex and parents may not be aware of these connections. Further, there may be family factors and stressors that affect the family and their health. As these issues can be difficult to discuss, it is important to invite parents to share their views and thoughts. The aim here is to gain insight into the family factors, including parental beliefs about weight, that may be affecting a child’s wellbeing.

You are interested in finding out about:

• worries parents have about other things happening in their life (e.g. financial concerns, family physical or mental illness)
• lifestyle factors (e.g. sleep routines, physical activities, sedentary behaviours, eating routines/diet)
• parents’ knowledge and beliefs about healthy lifestyles
• parents’ understandings of the connection between weight and mental health
• parents’ attitudes and beliefs about their own and their child’s weight, health, diet and body image, and how these may impact their parenting.

Examples of questions you could ask include:

• ‘Apart from caring for your children, what else have you got going on right now? What impact does this have on your day-to-day life?’
• ‘How do you feel about your body and your health? How does this impact on how you talk about yourself with your kids and those around you?’
• ‘What do you think will help [child’s name] to feel healthy and happy?’
• ‘How do you encourage [child’s name] to be healthy? What do you say or do to support this?’
• ‘Can you run me through a typical day for [child’s name]? For example, their daily routines, activities, diet, sleep…’

From these explorations and conversations about the family’s strengths, views, values and beliefs, it may be clear to you that there is at least one issue for further exploration. Alternatively, you may no longer be concerned and decide there is no need for extra support. The following section, How do I know what to be concerned about? offers guidance on potential indicators of risks for poor mental health and wellbeing.

On this page:

• Step 1: Tell the family what you’re concerned about
• Step 2: Use observational language to describe the concern
• Step 3: Seek parents’ initial thoughts about the concern you’ve raised
• Step 4: Summarise the information and ask parents if they’re concerned
• Step 5: Next steps
• More information on aspects of a healthy lifestyle

If, after exploring the family’s strengths and needs, you are concerned about the mental health and wellbeing of a child with higher weight, seek the parents’ views on your specific concern. In this stage, you are gathering information that helps you decide on next steps, rather than obtaining a comprehensive history of the problem or issue.

Following these steps can help:

Step 1: Tell the family what you’re concerned about, assuming responsibility for the concern

At this stage, you have the concern, not the parent. To avoid alarming them or provoking defensiveness, take ownership of the concern and ask for permission to discuss it further. For example:

• ‘You said that you think Tina needs to lose some weight and that you talked to her about going on a diet. Do you think we could talk about that a little more?’
• ‘Earlier today I heard you say that Luke is having a hard time at school; that he’s struggling with some of the other kids, particularly at recess and lunchtime. Would it be OK if we discussed that a little more?’
• ‘You mentioned that Katie has stopped going to dance class and doesn’t want to do anything other than stay in her room on her computer. Can we talk about that?’

If a parent doesn’t agree, accept their wishes and reassure them that you are there to help should they change their mind. If now is not a suitable time but they are open to further discussion later, set a time to meet in the near future. For example:

• ‘I can see that now isn’t a good time and I would like to get your thoughts on this as soon as possible. What times this week might you be available to talk it through?’

Step 2: Use observational language to describe the concern

Here you are trying to establish a shared understanding of the facts and to learn about a parent’s perspective on the situation. Avoid leading with a potential solution or an interpretation of the issue. For example:

• ‘During our last session, Naraya said she doesn’t like how she looks. She seemed unhappy. When did you first notice this happening?’

If your concern relates to a parent’s behaviour towards their child (e.g. a parent focusing on their child’s weight rather than their health), focus on the child first. This helps to prevent defensiveness and reinforces the stance of ‘you and I working together’ for the child. For example:

• ‘I noticed that when Isaac’s weight was mentioned, he looked pretty upset. Have you noticed that when you talk to him about his weight?’

Validate their experience and be quick to empathise. Let them know that you understand that there are good intentions and reasons behind their actions. For example:

• ‘It’s really hard to talk about this stuff and I can see how worried you are about Isaac’s health.’

It’s important that parents can see that you understand the level of challenge involved, and that you are not jumping to conclusions or judging them.

If you have a well-established relationship with a parent, consider supporting them to explore how their attitudes and behaviours may affect their child. If it’s early-on in your working relationship, this discussion may be too threatening for the parent, and it may be better to hold off.

In exploring parents’ attitudes and behaviours, you are trying to determine whether a parent sees their specific response as concerning (e.g. it has a negative effect on their child and/or they feel bad about it). In the context of higher weight, this discussion would focus on unhelpful parental weight-related attitudes and behaviours that may be contributing to the child’s poor mental health. For example, a parent:

• focuses on their child’s weight and weight loss, rather than health
• criticises the child’s weight/size/shape based on a misconception that it will motivate the child to lose weight
• displays their own body dissatisfaction and expresses unhappiness about their own weight in front of their child.

You might say something like:

• ‘How do you feel when you do that?’
• ‘How does Sam react when you talk about their weight?’
• ‘How do you think this makes her feel?’
• ‘How well is this working for you?’ (Reflect on the impact this has on the parent and the child. For example, how has focusing on the child’s weight affected their health and wellbeing? Has it had the desired effect?)

Step 3: Seek parents’ initial thoughts about the concern you’ve raised

Again, you are trying to establish a shared understanding of the concern. For example:

• ‘Is that right? Have I missed anything?’
• ‘Do you see it like that? Or is there something else that I’m missing?’

Step 4: Summarise the information and ask parents if they’re concerned

If a parent has noticed the issue, the next step is to find out if they’re concerned. Parents are unlikely to engage in further discussions and potential solutions to support their child if they’re not concerned.

Explore what a parent thinks and feels about the issue. For example:

• ‘We’ve been talking about how you’ve struggled with your body image and dieting throughout your life. You’ve mentioned that recently, Alisha has been complaining about her looks, picking at her food and wearing baggy clothes. Is this change in her behaviour concerning you?’
• ‘You said that you’ve noticed that Makayla has put on some weight recently. You also mentioned that she’s lost interest in hanging out with her friends and spends a lot of time in her room. You said that she has also been sleeping a lot more than usual lately. Do these changes worry you? Would you like to discuss them further?’
• ‘You’ve mentioned a few times that Rishal has stopped showing interest in the things he used to love doing, like dancing and swimming. Although kids regularly change their interests, I’m concerned that there might be more to him giving up on his favourite pastimes. I’m wondering what you think about this. Is this something that you’re worried about?’

Step 5: Next steps

If the parent is not concerned, let the family know that:

• if they would like to discuss this again in the future, they are welcome to call or make another appointment
• you will ask them about how things are going at their next appointment/scheduled phone call.

You may need to shift the focus to something else the parent is concerned about and is willing to work on. This might not address the concern at hand, but it keeps you connected with the parent and keeps the parent working with you. It gives the parent a chance to build trust and confidence in your approach. They may then be more willing to revisit the issue later or if things change.

If the parent is concerned:

Invite them to work with you. If they agree, you can begin working together to address the concern.

If, in raising your concern, you find that a parent has limited understanding of the connections between weight and mental health, your next step might be to provide them with psychoeducation or resources to increase their understanding, focusing on the particular concern that has been identified through this discussion. Emerging Minds’ Higher weight and mental health in children: Parent guide outlines some ideas, as do the resources listed at the end of this paper. A key step will be to link the information to the family’s concern (i.e. what they’re going through), including a discussion of how the resource or information will help or support positive change for them.

Following the conversation, you may also discuss mental health strategies that are part of integrated family-based interventions. These involve addressing health strategies to the whole family, rather than just the child. The actions you support parents to pursue could include enhancing interactions with their child (e.g. role modelling body positivity; taking the focus off weight or weight loss) and setting up healthy routines at home (e.g. identifying fun activities to do as a family; setting goals around eating meals together). You can find links to information about aspects of a healthy lifestyle, including tips for promoting a positive body image, in the following section.

As part of these discussions, it can be helpful to explore what parents have tried before and what has worked for them in the past in supporting their child’s health and wellbeing. It is also important to get an understanding of the parents’ readiness for change and any barriers that may get in the way (Mikhailovich & Morrison, 2007). Depending on your professional role, it can be helpful to set up a regular review with the child and family to continue to monitor the child’s mental health. Following up on any actions, providing feedback and celebrating any small successes will help to support positive change for the family.

Finally, you may consider referring the child for specialised support – for example, an occupational therapist to improve the child’s relationship with food through play therapy and sensory support; a psychologist to manage psychological distress caused by weight-related bullying, or difficulties at home or school). You might say something like:

• ‘We know from working with other families, one thing that helped them to make lifestyle changes is support from others. I can refer you now if you’re willing to give it a go?’

When providing referrals, let the family know what the service offers, who it’s for (the whole family or the child) and practicalities such as location, time, and length of service (Public Health England, 2017).

If you’re an allied health professional, you may refer the family to a general practitioner (GP) or paediatrician for further assessment/screening and support. GPs can also monitor families’ health and wellbeing over time.

References

Australian Institute of Health and Welfare. (2020). Overweight and obesity among Australian children and adolescents. Cat. no. PHE 274. Canberra: AIHW. 

Bradbury, D., Chisholm, A., Watson, P. M., Bundy, C., Bradbury, N., & Birtwistle, S. (2018). Barriers and facilitators to health care professionals discussing child weight with parents: A meta‐synthesis of qualitative studies. British Journal of Health Psychology, 23(3), 701–722. 

Lindahl, B. W., Kunz, C., Brownell, C., Tollefson, D., & Burke, B. L. (2010). A meta-analysis of motivational interviewing: Twenty-five years of empirical studies. Research on Social Work Practice, 20(2), 137–160.

Mihrshahi, S., Gow, M. L., & Baur, L. A. (2018). Contemporary approaches to the prevention and management of paediatric obesity: An Australian focus. Medical Journal of Australia, 209(6), 267–274. 

Mikhailovich, K. & Morrison, P. (2007). Discussing childhood overweight and obesity with parents: A health communication dilemma. Journal of Child Health Care, 11(4), 311–22. doi: 10.1177/1367493507082757. PMID: 18039733.

Miller, W. R., & Rollnick, S. (2013). Applications of motivational interviewing. Motivational interviewing: Helping people change (3rd edition). New York, NY: Guilford Press. 

Pont, S. J., Puhl, R., Cook, S. R., & Slusser, W. (2017) Stigma experienced by children and adolescents with obesity. Pediatrics, 140(6), e20173034. doi: 10.1542/peds.2017-3034.

Provvidenza, C., Hartman, L.R., Cosgrove, S., Hamilton, J., Crossman, S., Lyons, J., Anagnostou, E., & McPherson, A.C. (2017). Fostering positive weight-related conversations: Evidence and real-life learnings from the heart of care. A Knowledge Translation Casebook for healthcare professionals. Toronto, ON: Holland Bloorview Kids Rehabilitation Hospital. 

Public Health England. (2017). Let’s Talk About Weight: A step-by-step guide to conversations about weight management with children and families for health and care professionals. London, UK: PHE Publications.

Robinson, E., Daly, M., & Sutin, A. (2020). Association of parental identification of child overweight and obesity and mental health problems during childhood. International Journal of Obesity, 44, 1928–1935.

Russell-Mayhew, S., McVey, G., Bardick, A., & Ireland, A. (2012). Mental health, wellness, and childhood overweight/obesity. Journal of Obesity, 281801. doi: 10.1155/2012/281801.  

Small, L., & Aplasca, A. (2016). Child obesity and mental health: A complex interaction. Child and Adolescent Psychiatric Clinics, 25(2) 269–282. doi: 10.1016/j.chc.2015.11.008