Mental health in adolescents with obesity: conflicting views among physicians, a qualitative study

Mental health issues in adolescents with obesity are multifold, with no explicit screening recommendations. The aim of this research is to explore how this screening is performed by physicians and, thus, how it impacts adolescents' care pathways, offering insights into how to improve it through a qualitative study using interpretative phenomenological analysis. Twenty physicians (non-psychiatrist physicians and child and adolescent psychiatrists) involved at various stages in the care pathway were interviewed with semi-structured questionnaires. The findings connect 2 meta-themes. Non-psychiatrist physicians perceive widespread but ill-defined suffering in adolescents with obesity. Non-psychiatrist physicians see screening for mental conditions as mandatory. Unlike child and adolescent psychiatrists, they are not experts in distinguishing psychosocial suffering from psychiatric disorders. Screening is clinical. Adolescents' demand to lose weight in a context of shaming and alexithymia limits their access to psychiatric care. Child and adolescent psychiatrists then redefine the medical response to polymorphous symptoms. Psychiatric diagnoses mainly involve anxiety and depression symptoms, seldom eating disorders.    Conclusion: Physicians have overtly conflicting perspectives over the intensity of mental conditions. Non-psychiatrists, sensitive to perceived distress, seek to have it quickly appraised if they detect a significant suffering. Child and adolescent psychiatrists find appraisal complex to perform in the absence of means, interest, and/or experience. Improving screening requires training health professionals and using multidisciplinary assessment means. What is Known: • Mental health and eating disorders are contributing factors of obesity but their relationship remains complex between cause and consequence. • Mental health conditions and psychosocial suffering are the main complications among adolescents suffering from obesity with guilt, sadness, or stigma. What is New: • Non-psychiatric physicians express their need of a specialized diagnosis to define this suffering, but the lack of availability of psychiatrists and the necessity of time and of a multidisciplinary team lead to a delayed assessment. • For psychiatrists, this suffering is often not a psychiatric condition. Though requiring attention, this can lead to a misunderstanding between professionals.

Issues around food in mixed families of adolescent girls with bulimia nervosa: A qualitative study with photo-elicitation

OBJECTIVES

Bulimia nervosa (BN) is a common psychiatric disorder among adolescent girls with potentially significant complications. Family relationships play a major role in the development and progression of this disorder. Studies in migrant populations suffering from eating disorders show contrasting results depending on the generation of migrants: first generation migrants have fewer eating disorders than the native population, while the prevalence of this disorder is more important than the latter among second and third generation migrants. In our clinical experience, we have frequently encountered so-called "mixed" families, which are families composed of one migrant parent and one non-migrant parent. Research focusing on this kind of family is scarce which is why we chose to explore their dynamic.

METHODS

This study explored the issues around food and family relationships of adolescent girls suffering from BN, a topic that, to date, has not yet been studied. Ten interviews were conducted with five adolescent girls with BN between the ages of 16 and 20 and their parents, using photo-elicitation to enrich the collected data.

RESULTS

The results were organized around two axes: (1) identity issues around food, that is the assimilation process described by both parents and adolescents concerning family meals and food habits, and how the adolescents struggle to manage this interbreeding; and (2) transmission issues with the consequences the migrant parent has to deal with to transmit his/her cultural identity with food while being far away from the homeland, and the difficulties between this parent and his/her child to share this heritage. Both issues, identity and transmission, appear to be central among these families.

CONCLUSIONS

Our results suggest a difficulty in mentalizing identity issues in adolescent girls; the function of appeasement around non-mentalized tensions was highlighted. In our opinion, in this particular context, BN acts as a means of expressing the difficulty of their mixed culture. This enables it to draw some clinical implications, especially using mentalization-based therapy which has already shown efficacy in adolescents with borderline personality disorder and ED.

The experience of healthcare professionals treating adolescents with eating disorders in psychiatric and pediatric inpatient units for adolescents: A qualitative study

OBJECTIVES

The recommended treatment for Eating Disorders (EDs) is multidisciplinary and multimodal. Nonetheless, the complex linkage of the different disciplines involved is not necessarily simple. We analyzed the experience of healthcare professionals faced with psychiatric and psychological symptoms in adolescents with EDs in two "multidisciplinary" inpatient units embedded predominantly in different paradigms - one pediatric and one psychiatric.

METHODS

Qualitative analysis of 20 healthcare staff members' interviews from different professional backgrounds working in inpatient units for EDs in Montreal (Canada) and Paris (France).

RESULTS

The "Complex patients" theme discusses the need for a global approach to the multiplicity of symptoms presented by these patients. "Management and its limits" describes the daily management of psychiatric symptoms in both units. "Psychiatry and Adolescent medicine: from opposition to collaboration" describes the different levels at which these disciplines work together and how this cooperation may be evolving.

CONCLUSIONS

The complex entanglement intrinsic in EDs of the patients' somatic, psychosocial, psychiatric, and adolescent problems requires collaboration between disciplines, but the modalities of this collaboration are multiple and evolve non-linearly in specialized treatment units. A multilevel approach must be offered, with the degree of collaboration (multidisciplinary, interdisciplinary and transdisciplinary) appropriate to the complexity of each adolescent's issues.

[Qualitative study of parents' experience after their teen's suicide attempt]

INTRODUCTION

Suicidal attempts are frequent during adolescence and concern the whole family, particularly parents whose role is crucial in provision of therapeutic support. Yet very few studies have been performed bearing on their lived experience. In this study, we will analyze the experience of parents after the suicidal attempt of their adolescent.

PARTICIPANTS & METHODS

Qualitative study based on semi-structured interviews of 13 parents of teenagers followed in child and adolescent psychiatry for suicidal behavior. Interview included 5 to 6 open and conversational questions. We analyzed interviews, after transcription, using the Interpretative Phenomenological Analysis approach.

RESULTS

The parents' wellness and behavior are directly affected by their child's mental status. When they are informed of the suicidal attempt, they feel very deep sadness, in a form of initial distress which is part of the grieving process regarding their image of idealized parents. They feel anger against the teenager, their anger is also directed against family members and close friends as well as against caregivers. Given the uncertainty, they doubt their own educative and empathetic competences, and lack confidence in their capacity for providing help. They express their need for help and support with regard to understanding their child's suicidal attempt, with regard to the emotional turmoil they experience and in reinforcing their competencies as carers.

CONCLUSION

It appears that parents are extremely touched by their teenager suicidal attempt. They need a personal follow up, including familial medical care but also a personal space of support. Parents group, as well as psycho educative intervention, are also welcomed to give efficient method to lift their child.

[Female patients with eating disorders and their parents experience in China: A qualitative study]

INTRODUCTION

Recent tendencies show a stabilization in Western countries of the incidence of anorexia nervosa but an increase in Asian countries where it used to be lower. The emergence of these diseases in non-Western countries suggests a culture change syndrome on an individual or societal scale. The great number of changes having occurred in China in the past decades would favor the occurrence of eating disorders. A variability of symptoms of eating disorders can be observed depending on the cultural background which also influences the treatment. There are few studies that exist within an Asian context, and they mostly focus on the care.

OBJECTIVES

In this study, we intend to explore the experience of Chinese female patients hospitalized for an eating disorder and the experience of their parents: their relationship with the symptoms, with their health and their understanding of the disease, in order to identify the impact of the Chinese cultural context upon the disorder.

METHOD

It is an observational, phenomenological and qualitative study. A purposive sampling was formed from a clinical population group of young teenagers and women, coming from various areas of China and hospitalized in the specialized Psychosomatic Department of Shanghai Mental Health Center, in August and December 2017. The degree of urbanization, the regions and ages categories were wide-ranging, allowing us to maximize the richness of the data assessing the disease and care representations. Two semi-structured interviews were realized with the participants, then with one or both parents. The interviews were realized with an evaluative interview guide by the same researcher together with a Chinese psychology student in order to clarify the translation and the interpretation of the cultural elements expressed by the participants. The analysis was based on the Interpretative Phenomenological Analysis. Two researchers read the interview transcripts several times, identified themes then connections between the themes to build a set of meta-themes depicting the narratives. Every meta-theme was linked with its corresponding themes which necessitated during the analysis constant back and forth between the analytical data and the source material.

RESULTS

Thirteen female patients and 11 parents took part in the study. The patients were between 12 and 31 years of age. They showed a wide range of eating disorders: restrictive anorexia, anorexia nervosa, or bulimia nervosa. Their Body Mass Index at the time of the interview ranged from 11 to 22. Three meta-themes emerged from the analysis: concerns about thinness and health are real catalysts for seeking care, the opposition between parental beliefs about factors of good health and eating symptoms in young girls, and changes in parenting and traditional educational methods induced by eating symptoms. These different themes highlight the fear of thinness and good health being powerful therapeutic levers in China, the intergenerational agreements and disagreements on the factors of good health with the parental experience of consideration around the eating disorder of their daughter, and an impact of traditional educational modalities on the family relational aspects that change with the disorder.

DISCUSSION

Exploring the experience of young Chinese girls or women suffering from eating disorders highlights the complex interactions between the cultural and clinical context of eating disorders. Weight loss is experienced with great difficulty by the young women of our study, who report somatic symptoms and worry about their thinness. Our results show the central position occupied by maintaining oneself in good health in China, for parents and teenagers alike. This allows a quick reliance on healthcare. The intergenerational differences in China are increased by the rapid changes occurring within Chinese society which can cause conflicts and particularly violent struggles. Its younger generations are becoming more and more globalized. These results provide further evidence that eating disorders are culture change syndromes. The therapeutic impact of our results is twofold. On the individual level, there are therapeutic cultural levers linked with Chinese culture, and they have to be sought in all cultures. The therapeutic education of Chinese patients must be centered on the somatic consequences of the disease in order to increase the adherence to the care. On the familial level, the therapeutic approaches centered on intergenerational conflicts must be developed.

CONCLUSION

The rapid sociocultural changes in China are causing important intergenerational differences, notably between traditional educational modalities and the need for independence of young people who require specific familial therapy. The cultural elements must be taken into account in order to understand eating disorders and to develop relevant therapeutic approaches.

[Adjustment of healthcare and telemedicine in times of lockdown and COVID-19 pandemic: Feedback from a "Maison des Adolescents" (Teenager's House)]

La crise sanitaire de la COVID-19 a imposé une réorganisation majeure de l’offre de soins en France. Considérant la nécessité de maintenir des soins pour les adolescents souffrant de troubles physiques ou psychiques, les Maisons des Adolescents ont dû adapter en urgence leurs pratiques afin de maintenir au maximum la continuité des soins pour les adolescents et leurs familles. À travers le cas d’une adolescente qui a présenté une dégradation clinique de son anorexie mentale durant le confinement, nous présentons les réorganisations des soins au sein des différentes unités (consultations–hôpital de jour–unité d’hospitalisation temps plein) d’une Maison des Adolescents parisienne au cours de la pandémie de COVID-19. À partir de la littérature existante, nous discutons les avantages et limites de la télémédecine et les enjeux pratiques pour l’organisation future des soins pour les adolescents. Contrairement à la médecine pédiatrique ou pédopsychiatrique, il n’existe pas de protocole décrivant la mise en place de la télémédecine en médecine et psychiatrie de l’adolescent. Il est urgent d’approfondir les évaluations de l’utilisation de la télémédecine pour les adolescents. Ce type de recherche permettra d’améliorer les connaissances sur l’efficacité, l’acceptabilité et les limites de l’utilisation d’un dispositif de téléconsultation en psychiatrie de l’adolescent, en contexte de crise. Certaines modalités de soins à distance mises en place pendant la crise pourraient ainsi être maintenues dans le temps et s’inscrire en routine dans le domaine de la médecine et psychiatrie de l’adolescent.

[Suicidal behaviors in migrant youths: Male experiences]

OBJECTIVES

Suicide is the second leading cause of death among adolescents. Boys are more affected than girls, although they report fewer suicide attempts and rely less on care. Few studies have examined the experience of suicidal thoughts and behavior among young boys. In order to improve their health care, it is necessary to consider the socio-cultural aspects and the construction of the meaning given by adolescent boys to suicidal behaviors in France.

METHOD

This is a qualitative, complementary and inductive study. All teens included have presented suicidal thoughts in the months preceding the inclusion. The existence of self-mutilation and/or suicidal act is sought but is not included within the criteria of inclusion, the various contexts will enrich the data. Semi-structured interviews are transcribed and analyzed by the Interpretative Phenomenological Analysis.

RESULTS

Ten adolescents between 14 and 20 years old were included in the study. Three axes of experience emerge: the relationship to oneself, the relationship to the other, the relationship to death. Some themes are common to experiences of both boys and girls, others are more specific to the boys' experience. The inner struggle, testing one's limits and an isolating unspeakable are thus common, highlighting the difficulty for adolescents to mentalize and verbalize emotions and feelings. Difficulties in connecting with others, and feelings of loneliness and isolation, are at the core of the participants' experience. However, the experience of boys appears specific in the difficulty to represent the irreversibility of death which can lead to suicidal behavior without direct intentionality. The narrative of suicidal acts, in its formulation, is quite different from that of young girls. One can assume that the difficulty of expressing suffering could lead young boys to develop a discourse that overshadows the question of their death, or in contrast magnifies it in a rewarding stage from which they pride themselves. The fear of being isolated or rejected seems almost insurmountable for the boys interviewed. The fear of the judgment of peers or the family is mixed with the imperative to face the problem by oneself and reinforces the feeling of isolation in a retroactive loop. The story of the suicidal act can take a positive and enriching tone in the participant's stories. This only applies to adolescents with a history of suicidal gesture. The experience of acting out and its consequences seems to be integrated by the adolescent as elements which participate to a certain extent to the construction of their identity. This ameliorative feature can be compared to the hegemonic social models of masculinity. The sociological notion of gender identity makes it possible to think of this construction in a dynamic way and to propose adaptations of the caregivers' attitude during the first interviews with a suicidal teenager. During the first meetings, the caregiver should explore the adolescent's representations of the suicidal crisis in a neutral, self-interested, and unbiased way, including when the representations are disturbing or shocking for the caregiver. For example, when the patient values or glorifies suicidal behavior or when care is experienced as a sign of weakness and vulnerability. Respect of these proposals can indeed support weakened narcissistic foundations and favor encounter and alliance. This can only be done with the conviction that these representations are not frozen, but in construction, and that they can be secondarily mobilized in the therapeutic relationship. For that purpose, a work of elaboration on the representations of the masculinity will be able to lead the young person to reconsider his perception of care and suicidal behaviors. Reflexivity on the part of the caregiver about his own representations of masculinity seems necessary.

CONCLUSION

Therapeutic management must explore and respect the adolescent's representations of masculinity and then mobilize them to bring the young person to reconsider his perception of care and suicidal behavior.

Research in adolescent healthcare: The value of qualitative methods

BACKGROUND

The vast majority of publications about adolescent healthcare use a quantitative methodology that often involves long and expensive research protocols with results that do not always provide answers adequate to the complexity of the questions being asked. The qualitative method is sometimes a more effective alternative for exploring some of these. This method can be defined from its objective, which is to generate theoretical hypotheses, its mandatory consideration of the researcher's subjectivity, and the importance it ascribes to the context of the participants' experience. Among the many techniques of qualitative research, the use of phenomenological methods, in particular, interpretative phenomenological analysis (IPA), is highly developed in medical research.

OBJECTIVES

To define the qualitative method and describe the principal stages of a phenomenological qualitative study.

RESULTS

The three stages of a qualitative study are data collection (population and sampling, data collection methods), data analysis, and writing up the results. Purposive sampling makes it possible to include participants who can describe in detail, and as experts, their experience during semi-structured interviews. The analysis takes place in two stages, the first very descriptive, the second more interpretative. The results are written-up in a narrative form, including both direct quotations from the interviews and the researchers' interpretation.

DISCUSSION

The issues of health promotion and healthcare associated with the management of chronic symptoms or diseases in adolescents involve an extremely rich and complex context. Qualitative methods make it possible to approach these questions and to understand them better by generating hypotheses from a rigorous scientific procedure appropriate to the context and objectives. In addition to being used on their own, they can be used on an exploratory basis early in a quantitative study to help define it better, for explanatory purposes, to help understand complex quantitative results, or combined with a quantitative study. The qualitative and quantitative results will then be integrated.

[Impulsivity and obesity in children with Attention Deficit Hyperactivity Disorder: A clinical, neuropsychological and magnetic resonance spectroscopy exploratory study]

OBJECTIVES

Relationship between Attention Deficit Hyperactivity Disorder (ADHD) and obesity in adults and children had previously been established in research studies. Brain imaging studies pointed out the important role of the prefrontal region in both ADHD and obesity. However, the underlying link between ADHD and obesity is not well understood. The hypothesis that impulsivity could play a role has been explored in clinical studies of ADHD and Binge Eating Disorders or Loss of Control Eating, with contradictory results. Our study aims to compare children with ADHD and obesity to children with ADHD and normal weight. We propose to compare these two populations with clinical, neuropsychological and brain spectroscopy investigation, focusing specifically on impulsivity items.

METHOD

Ten children presenting overweight or obesity were selected from a larger population of children with ADHD (5-12y) and paired with regard to gender and age with ten children with ADHD and normal weight from the same population. Conners Rating scales version parents (CPRS) and teachers (CTRS), Conners' Continuous Performance Test II (CPT-II), and Magnetic Resonance Spectroscopy (MRS) metabolites in five regions of interest (left and right prefrontal, left and right striatal and left cerebellum regions) were measured for all the children. For MRS, ratio to creatinine levels of following metabolites were measured: glycerophosphocholine+phosphocholine/creatinine (GPC+PCh/Cr), glutamate+glutamine (Glu+Gln/Cr), myoinositol (mI/Cr) et N-acétylaspartate+N-acétylaspartylglutamate (NAA+NAAG/Cr).

RESULTS

Hyperactivity/Impusivity and Conners Global Index (CGI) subscales of Conners rating scales showed a higher rate of impulsivity in children with ADHD and obesity as compared to children with ADHD and normal weight. Neuropsychological results were comparable in the two groups. Finally, MRS showed a higher GPC+PCh/Cr ratio in right prefrontal cortex in children with ADHD and obesity as compared to children with ADHD and normal weight.

CONCLUSIONS

Our results are concordant with the hypothesis that impulsivity could be the link between obesity and ADHD in a population of children with ADHD. The right prefrontal regions seem to be areas of interests that need more research in the study of the link between obesity and ADHD.

A qualitative exploration of the work of embodiment in adolescent girls with obesity

Social representations generally associate obesity, especially in adolescent girls, with sedentariness, lack of self-control and laziness. These girls thus have substantial problems of self-esteem. Dietary, lifestyle and behavioural approaches alone cannot address this issue, for they do not apprehend all of the complexity of obesity. This qualitative study is based on a dual observation: that the work performed by adolescents is unrecognized and that the body is not considered as a subject of analysis. It raises the question of the corporality of these teens through an original perspective: that of the perspective of their organization of actions on, to and by the body, in specific situations. The objective is to have access to the corporal experience of young girls with obesity, so that we can understand and support them better. The data come from semi-directive interviews with 10 adolescent girls with obesity. The content was analysed in terms of concepts of professional didactics (a branch of educational psychology) and enaction. Five situations were identified from these interviews: the first, shopping with friends, concerns actions by the subjects towards their bodies; the other four are enacted actions: conduct towards a normal-weight person, conduct in public transportation, performing physical activity, and eating. The results show the work of these young women with obesity, the means they mobilize to live in their bodies and their considerable efforts of embodiment. Recognition of this work should help to enhance their self-esteem. Treatment and support may take this dimension of work into account and help them to become aware of the efforts they make every day.

Qualitative studies among obese children and adolescents: a systematic review of the literature

Childhood obesity is a complex condition involving medical, social, moral and cultural issues. Qualitative approaches are of great value in understanding this complexity. This meta-synthesis of 45 qualitative studies deals specifically with the issue of obesity in children and adolescents from different perspectives--those of obese children and adolescents, of parents, and of health professionals providing support to the family. Our aim was to obtain a coherent view of child and adolescent obesity, focused on clinical and personal experience. The themes derived from the synthesis process fall under three main axes: 'Seeing others, seeing oneself', 'Understanding others, understanding oneself', and 'Treating others, treating oneself'. It emerges that participants in all three groups had equal difficulty in perceiving and labelling obesity, mainly because of their lack of any real common ground. The insufficiency of shared representations destabilizes the therapeutic relationship and its construction: an important issue in the doctor-child-parent relationship in this context is the need to exchange their viewpoints of obesity. Health workers may also expand their understanding of obesity by incorporating the personal experiences of obese children and their parents in order to match treatment plans to their needs and expectations.