For help with
these issues, please contact:
Jane Rachel Kaplan, Ph.D., MPH
902 Curtis St.
Albany CA, 94707
A Most Tender Balance:
Behind-the-Scenes Treatment of
Children and Teens with Obesity
Your child is
overweight and you don’t know what to do… everything you
try seems to backfire.
This article is designed to help parents and
practitioners understand the ways parents can effectively aid a child
or adolescent in dealing with a weight problem even if the young
person is not directly involved in treatment.
The growing epidemic of obesity among children and adolescents demands
that clinicians develop increasing expertise in helping these young
people. When professionals attempt to intervene to combat overweight or
obesity, they must move cautiously to avoid triggering eating-disordered
behaviors such as overeating or under eating. More child-friendly
interventions are in order. This paper explores the intervention
approach I call working behind-the-scenes.
Just as lighting and stage crews collaborate with costume and makeup
artists to create the scene for a dramatic performance,
behind-the-scenes work with the appropriate professionals allows parents
to play a key role in shaping the drama of their child’s life and
health. A primary advantage of the behind-the-scenes method is that the
child can often be left out of treatment proper, yet ultimately benefit
The most important aspect of any successful treatment, including
behind-the-scenes work, is first viewing the young person in a
multifaceted, holistic way. I use multi-modal treatment for treating
children and adolescents with obesity and weight management issues. This
process involves soliciting viewpoints from practitioners such as the
physician, dietician, and psychotherapist. Through such a partnership,
more child-friendly interventions can be designed.
However, multi-modal treatment also includes participation from the
other very important members of the team, the parents. As Virginia Satir
wisely told us years ago, the parents are the architects of the family1.
In behind-the-scenes work, I work comprehensively with the whole family.
Individual treatment, which can be very useful at times, and even the
treatment of choice for some, unfortunately can sometimes result in
minimal consideration for a young person’s surroundings and home life.
For example, when Hannah talked to her therapist about her home life,
she gave the impression that the family rarely ate meals together. When
the therapist interviewed Hannah’s parents, she learned the family ate
together three times a week, though Hannah often begged to be excused
from dinner. The exciting family-oriented Maudsley approach, which
treats anorexic children and teenagers under the age of 18 living at
home, employs this parental power in a very proactive way. It has
achieved impressive results for anorexia nervosa.2
Behind-the-scenes work also attempts to harness parental power to
improve the child’s health.
I recommend caution when one is considering weight loss for children and
adolescents. Weight loss itself could interfere with normal development
and growth. For instance, in puberty, when girls are accumulating a good
deal of their life time bone mass, a great reduction in calories could
cause decreased growth and weaker bones. Whenever possible, I recommend
weight maintenance while height increases. It can be useful for a team
of multi-modal providers be included in decision-making about weight
loss for individuals who are not fully grown and developed.
During outpatient treatment of obese children and adolescents, my goal
is to support healthy eating, active living, and size acceptance for
all, principles derived from the work of Frances Berg.3 To
accomplish these aims, I harness parental power and work with the
multi-modal team (a physician and a dietician in addition to myself, the
psychotherapist) to modify the food environment. One practitioner takes
the lead and organizes communication channels with the other
practitioners and with the parents.
Assuming the psychologist is the lead practitioner, she works with the
treatment team and the parents to develop a plan for the entire family
for more active living. They explore ways to increase the activity level
of the child, if deemed necessary. Then she works with the family to
implement the plan and creatively amends it as the process unfolds over
A family plan for more healthful eating, which includes building in
reasonable amounts of treats and sweets, is developed. Each family’s
food likes and dislikes, shopping habits and values about food are taken
into consideration in developing this plan.
The psychologist also explores parental attachments to dieting. For
instance, a father might be into the latest diet fad (or be in rebellion
against dieting) and need professional guidance to reconcile this with
the desire to help his struggling son or daughter. Child and adolescent
weight management is most effective when the entire family improves
their eating habits, so that the child does not feel singled out. The
psychologist and others on the treatment team can all be instrumental in
helping the family to eat in a healthier manner.
The third element of multi-modal treatment involves dealing with the
psychological aspects of weight and body. In my experience, the higher
the body-esteem, the easier weight management becomes. It is challenging
for a child or adolescent who dislikes her body and its size to even
consider improving body-esteem. The therapist, dietician and physician
can all encourage this position. The therapist can work with the parents
to create an atmosphere of size acceptance, which is affirmed as well by
the physician and dietician. The child can come to understand that
changes can be made for the health of the family, rather than the child
being wrong for being overweight. In the end this really is about
health. The therapist can help the parents begin to teach the child
media literacy (the ability to critique TV shows, ads, etc. rather than
taking them at face value, especially as regards dieting and body
Additional psychological issues may be at play. These include the
child’s tension around food, the use of food for after-school
gratification, and other dysfunctional uses of food by the child or
family. Even without the child’s direct involvement in treatment, the
psychologist can help the family deal with these issues in a healthier
way. For instance, the therapist may bring to light a parent’s own low
body-esteem and help him or her with it. This may help the parents
develop a healthier perspective on themselves, which would lower tension
in the family, freeing energy for them to develop better ways to deal
with their child’s eating and body esteem issues.
The psychologist and other members of the team can provide input to
enhance the treatment process. However, at times, families may not be
able to access or afford several members of the treatment team. They
might work only with the physician, dietician, or therapist, with
perhaps infrequent visits to other team members. In this case, the team
member who is the primary contact will work with the whole range of
elements as well as possible, while networking with the others on the
treatment team for consultation and joint planning.
I have seen very successful outcomes from behind-the-scenes
interventions. However, at times, it is important that the child be in
session with parents and speaks with the practitioner. This can be the
case when behind-the-scenes treatment is providing insufficient
information, or the child expresses an interest in meeting with
practitioners for direct help. Similarly, in some situations working
with the child directly may be the treatment of choice, especially if
the patient is an older teen. Teens may want to be included in order to
“have a voice", and some may do better with their own therapy which
includes occasional family meetings. On the other hand, some teens may
be so resistant to psychotherapy or other treatment that a
behind-the-scenes approach is the only avenue available to concerned
parents. Each situation must be evaluated on a case-by-case basis, and
re-evaluated as treatment progresses to see if it is effective.
Here are some examples of behind-the-scenes work.
Ethan is the son of divorced parents. The
pediatrician felt that Ethan was overweight and his mother, Danielle,
agreed but she had not been able to successfully help him with his
weight. The pediatrician referred Danielle, his dad, and stepfather to
me for help.
When Danielle called to make the appointment, she explained that Ethan
lived in two different homes, and she felt the different eating styles
were contributing to his weight problem. I learned that she had been
very frustrated in trying to help him with his weight and felt that she
was out of options. Her friend’s teenage son had an eating disorder and
she was really frightened that pushing Ethan to eat less might create
one in him. I asked Ethan’s parents and step-parent to come without him
to examine the big picture.
At the first session, Ethan’s biological father, Ray, expressed surprise
and annoyance that Ethan was left out of the initial visit, but as the
visit progressed, he began to see how important it was for the parents
to first understand their own goals and feelings. It emerged that Ray
was also threatening Ethan with “having to go see a shrink if he didn’t
watch what he was eating and start exercising.” Ray angrily complained
that he had bought Ethan an expensive bike but he wasn’t using it — instead,
Ethan preferred playing video games.
Ethan’s stepfather, Steve, had several medical problems and had
struggled with his weight all his life but currently was doing well
going to the gym during the week. However, he had trouble controlling
his eating and sticking to his food plan. Ethan’s mother, Danielle, was
a petite woman who was currently helping her husband, Steve, to follow a
high-protein diet, which changed the usual type of food and snacks
available in their household.
With three parents involved, each with a different relationship to food,
eating, exercise, and weight, there was a lot to sort out.
At the first meeting, I focused on two issues: What factors contributed
to Ethan’s eating and exercise patterns, and what were the parents’
One issue was that Danielle had eliminated all the snack foods with
carbohydrates from her household. This meant that Ethan consumed a
reduced-calorie diet during the week, providing insufficient calories to
support his growth. At Ray’s house, with unlimited access to
carbohydrates, Ethan hoarded food and overate.
Also, Ray worked at least six days a week, and sometimes part of Sunday
morning. He expected Ethan to play on his own, but Ethan didn’t have
many friends in that neighborhood, so he stayed in and snacked. A
plethora of candy wrappers in the wastebasket told the story of his
after-school purchases. In addition, Ray expected Ethan to just gain
control of the situation and do something about being fat.
My first job was to get Ethan off the low-carbohydrate diet his mother,
Danielle had put the family on. I emphasized to the parents the
importance of a balanced diet and how restrictive eating often leads to
The next item I tackled was exercise. I worked with Ray on his
expectations for Ethan, and helped him to understand that expecting him
to exercise alone was not realistic for a boy of Ethan’s age. During the
next two sessions, family-based plans were developed for each household.
Ray decided on a Sunday family walk. Steve interested Ethan in the idea
of a karate class. Danielle worked to enroll Ethan in the class, and the
other parents agreed to support this emotionally and practically through
driving Ethan to class regardless where he was staying.
Ray and Danielle’s parental guilt about the divorce also came to the
fore. Ray admitted that he felt comforted in seeing Ethan indulging at
his house: “It really made me feel good to see Ethan grazing, like he
felt comfortable in my house, and like he had forgiven me for the
divorce.” I encouraged Ray to have several conversations with Ethan
about the divorce, and to let go of his own guilt. It was heartwarming
to see the other parents help Ray forgive himself. In addition Danielle
was able to see how her anger at Ray had stopped her from communicating
with him about Ethan’s needs. She began to communicate more directly
In the first few sessions, parents reported that Ethan was making no
progress. In fact, he was complaining more about being “forced” by Ray
to exercise. This makes sense because the parents were just beginning to
understand the issues at play and to formulate some initial strategies.
After a couple of weeks of family walks with Steve and Danielle, Ethan
began complaining less and even looked forward to the walks, which were
often followed by a healthy family lunch at a favorite restaurant. In
fact a couple of months later Ethan was the one initiating the walks,
and complained if they did not happen.
He was willing to try karate and was a mixture of interested and
frightened of looking inept. The parents told him he should try it for a
few months and it was up to him if he wanted to continue. The karate
teacher was a overbearing and Ethan became uncomfortable. Danielle and
Steve tried to work it out with the teacher, but it just was not a match
for Ethan. They switched him to another karate school which Ethan liked
better and where he made a new friend.
Ethan asked Danielle why she had gotten new (complex carbohydrate)
foods. He thought that was very strange and was worried that they could
“make Steve sick”. He begged his mom to take them away. Steve and
Danielle explained that there would be “Steve-friendly” foods for Steve,
“Ethan-friendly” foods for Ethan, and “Mom-friendly” foods for Danielle.
They could also share and taste each others’ special foods and there
were tons of foods that everyone liked and could eat. This seemed to
calm Ethan down a bit, though he seemed skeptical. As the months went
on, he relaxed and got used to the new regime. He sometimes spotted a
special “Steve-friendly food” at the supermarket and pointed it out to
Ethan, too, liked grazing at Dad’s house, and food was something he
enjoyed sharing with Dad. As Ray encouraged Ethan to eat a healthy
after-school snack, he watched Ethan slowly adjust to this. At first
Ethan wanted the planned snack plus the grazing, but was told that he
needed to wait until dinner; however he could graze on the veggie
platter which was on the dining room table. His dad told him that this
was so he would not spoil his appetite for dinner, and never mentioned
the words “weight, overweight, or overeating”. Ethan told his dad that
he thought both families were “crazy health nuts”.
Though I never met Ethan, I was very pleased to work with him. The work
with his parents brought them together for the sake of his health and
showed them they could be effective as a team. It also helped them
address some old wounds and issues, such as Ray’s guilt, that would have
only gotten in the way of Ethan’s development whether on the level of
food, relationships, or on other levels.
I spent about twenty sessions working with Ethan’s parents and
stepparent. There was also considerable phone contact to help tweak the
plan and deal with issues between sessions. After our more intense
initial work, I continued to meet with Ethan‘s parents bi-weekly and
then monthly. After that, we met every three months, then every six
months, and then as needed, which turned out to be about once a year. As
Ethan grew in height, his weight increased more slowly. He looked
thinner and was no longer in the overweight category. His parents and
physician were pleased with the many changes that had occurred.
Patients rightly ask, “How long will this take?” Some families do well
with three to five sessions with the psychologist. Others families need
more support and a greater opportunity to work on family dynamics which
are interfering with the child’s inability to use food and exercise in a
healthy way and to have a healthy body esteem.
Sometimes a child has psychological and social problems which contribute
greatly to the obesity. In these cases, parents often need more sessions
with the psychologist to help them sort out how much they can do to as a
part of the weight management work or if they need to bring in
additional resources. These other interventions can be such things as a
social skills group or individual therapy for the child.
No matter how few or many sessions constitute the initial treatment,
follow-up is key and related to a good long-term outcome. Monthly
follow-up sessions often work well for parents. Limited financial
resources sometimes prevent families from having the ideal number of
sessions, and in this case parents need to speak frankly about this to
the psychologist so all can work together to get the most benefit from
these more limited sessions.
Jessica is a moody high school student who
loves art and music. She has few friends and those she has don’t last
long. Jessica is very shy and really dislikes her overweight body. She
spends a lot of time fantasizing about being thinner and how this would
bring her more friends, perhaps even a boyfriend, and an easier life
Her parents had suggested therapy many times over the last five years
and even persuaded Jessica to go once or twice. However, Jessica felt
she was not getting anything out of it and dropped out of treatment.
When the parents came to see me, they were very concerned and felt that
time was running out for them to help Jessica directly, for she was
already a junior in high school. In addition, her weight was increasing,
though her height was not increasing and her pediatrician was concerned.
Jessica’s blood pressure was too high and there was a family history of
The parents and I devised a four-part plan:
1) Exercise: They would encourage family exercise by walking
around their local shopping area to do errands, followed by a visit to a
shop Jessica really liked. In bad weather they would walk around the
local mall and shop, or see a movie together. These outings were not
always enjoyable for the parents or Jessica and so the plan was changed
a bit, with one parent taking Jessica out and the other getting a break.
They told Jessica that they felt family time was important and getting
out of the house was good for them all. They tweaked the plan again and
found that when mom took Jessica out for a manicure and a walk, they
both had fun and it presented an opportunity for mom to bond with
2) Body-Esteem: Jessica’s mom, Bonnie, tendency was to make
repeated comments and judgments about bodies and how they looked.
Though, Bonnie was never directly critical of Jessica, this was making
Jessica feel bad about her own body. I coached Bonnie on the importance
of body acceptance and encouraged her to share this value with Jessica
through low-key and sincere comments. This improved Jessica’s body
esteem over time. It gave her mom an opportunity to show her love and
concern in a more positive way.
3) Social Functioning: As we talked together, the parents and I
came up with the idea that Jessica might benefit from a social skills
group. We investigated the groups in the area and found one led by a
very experienced social worker who had been leading teen groups for
fifteen years. Bonnie and I both interviewed the leader and felt this
could be a match for Jessica.
Jessica was reluctant to be in a group “full of losers”. The parents
were insistent that she try and pointed out to her very frankly that
they thought she lacked skills which were necessary for developing
friendships and that they wanted her to get these skills before college.
Jessica very reluctantly interviewed for the group. She begrudgingly
began the group and after a few months, it appeared to her parents that
it was helping her. Slowly her friendship patterns evolved. It was two
steps forward and one step back, but Jessica was on her way.
4) Food: The parents decided to work on these other levels and to
leave Jessica’s eating habits as they were for the first few months.
They were busy initiating the exercise program and finding the social
skills group. When they began to take on the food, the first change they
made was involving Jessica in helping to cook a couple of meals a week.
Both parents used to enjoy cooking and had done less cooking as their
lives had gotten busier. They were able to shop and cook with Jessica
who began to be proud of her ability to make some special dishes. They
began to go to Farmer’s Market with or without her, and began to
emphasize more fruits and vegetables in the house.
Jessica’s little sister, Emma, was a very athletic girl and though she
loved Jessica very much, she was so busy with her friends and activities
that they spent very little time with each other. Emma was jealous of
the attention Jessica was currently getting and lamented, “She’s your
little darling. You take her out a lot and you’re spoiling her. I never
get anything. I don’t matter to you. Why should I try so hard when you
don’t care?” The parents realized they needed to reassure Emma and give
her more direct attention. They again invited Emma to go on some of
their family outings that she had initially refused to join. They also
blended in errands specifically for her. As Jessica’s social skills
increased, she reached out to Emma and became more of a big sister than
she had been in years.
Jessica was able to lose six pounds in the year I worked with the
family. This was actually a significant amount since she was still
growing. Her blood pressure decreased and her doctor gave her a lot of
positive feedback about this. Best of all, from her point of view, she
was able to make and keep friends. She told her parents it didn’t have
anything to do with the social skills group really but rather, she had
just grown up. He parents smiled and congratulated her on her improved
social life, knowing all the time that the group and the hard work they
put into behind-the-scene work had paid off handsomely.
As a psychologist, I have worked for 20 over years behind the scenes
with parents concerned about their children’s food, eating, weight and
body image. During the first sessions, we map out the problem and begin
to develop possible solutions. In the next sessions, we create a game
plan which parents begin to implement at home with their child. This
game plan is revised in subsequent sessions. New creative ideas are
added, while ideas that do not work are subtracted. Working actively
together helps parents feel empowered, as they take the reins and see
themselves more as teachers trying new strategies with their pupil. This
approach is often comforting to parents, for they know that they are
doing everything they can without directly involving the child in
therapy. It also lays a firm foundation for continuing work the child
may need. This could include family therapy, individual therapy for the
child, nutrition consultation with a dietician, or ongoing monitoring
with the physician.
There are both advantages and disadvantages to every kind of treatment
including behind-the-scenes work.
Advantages of behind-the-scenes work include:
1. With professional assistance, the parents are empowered to think and
work with their child’s issue. This helps increase their sense of
competence and build their parenting skills.
2. Once parents learn to more accurately understand and work with their
child, they can detect early signs of distress with food or in other
areas, and manage minor slip-ups before these become major problems.
3. The child does not meet with practitioners, and thus does not run the
risk of feeling like a patient or a sick person.
4. This work also forms a base of parent-practitioner teamwork and trust
which can set the stage and facilitate the process if the child needs
Disadvantages of behind-the-scenes work include:
1. Practitioners do not have the benefit of understanding the child and
her world directly.
2. Some parents feel overwhelmed and experience this work as yet more
burdensome. Therefore, they may not engage fully in working behind the
scenes. If this is the case, it might be better for the child to be in
individual treatment with occasional parental consultation.
3. Discouragement if behind-the-scenes work does not help might make it
harder for parents to then utilize family therapy or individual therapy
to help their child.
4. Families can be intimidated by an active model such as this, which
demands parental involvement, and may bring up feelings and family
dynamics previously hidden. In some cases, the parents may also need
time to work through their own issues. While this can be fruitful, it
can be an agenda parents are not interested in at that point.
Behind-the-scenes work provides families and clinicians with another
tool for helping deal with the challenges obesity presents. Every family
needs a tailored approach. Since I also facilitate individual and family
therapy, I work with parents to determine which approach would be best
1. Satir, Virginia, Peoplemaking, 1972. California: Science and
Behavior Books, Inc.
2. Lock, James, Le Grange, Daniel, Agras, W. Stewart, and Dare,
Christopher, Treatment Manual for Anorexia Nervosa: A Family-Based
Approach, 2000. New York: The Guilford Press.
Lock, James, Le Grange, Daniel, Help Your Teenager Beat An Eating
Disorder, 2005. New York: The Guilford Press.
3. Berg, Frances, Afraid to Eat: Children and Teens in Weight Crisis,
1997. North Dakota: Healthy Weight Publishing.
* I wish to thank the talented Michele R. Vivas, M.S., R.D., and Janelle
L. White, Ph.D., for their support, ideas, and help with this article.
* I welcome your perspectives about your own behind-the-scenes work.
What do you think of this approach? Have you ever tried it? If not do
you think it may have value? If so, has it helped your situation? What
are the advantages and disadvantages you have experienced? Thank you for
your interest. - Jane
Let us know by clicking here.
© Copyright 1997-2012 Jane Rachel Kaplan, Ph.D. All rights reserved.
Dr. Jane Kaplan Ph.D., Psychologist Provides Eating Disorders Therapy in the SF East Bay area, near Berkeley, Albany. Weight Management Coaching, Psychology of Nutrition and Healthy Eating Counseling, Individual, Group and Family Therapy for Anxiety and Depression.