Objective of the session

Content of the session

Initial session is basically devoted to the rapport formation along with the psycho-education of obese adolescents and their parents. They are informed about the findings of the detailed assessment. A brief orientation to therapy process is also provided by specifying the number and frequency of the session. Therapist emphasizes the collaborative approach of CBT and encourages the active participation of adolescents and parents. Parents are also informed about their important role in the treatment process and how their involvement can affect the treatment outcome in a positive manner. They should be informed about the long-term aspect of treatment, weight loss and weight maintenance phase of the therapy. It is also important for the therapist to ensure that the adolescent and parents understand the rationale of different CBT techniques to target the specific behaviour change.

Psycho-education for obese adolescents and family does not mean that therapist is educating them about their weight and associated risks; however, therapist assumes that they know about their weight problems. With this assumption in mind, therapist can simply explain the BMI status of the child and ask them in a very non-judgemental manner “what do you think about it”, and this approach allows the adolescent to open up about the problem and get more involved in the process of behaviour change. After listening to the adolescent’s perspective, therapist educates the adolescent and parents about the need for healthy lifestyle changes and weight control.

The first session also incorporates the rationale and importance of self-monitoring. By using this technique, therapist asks the adolescent to record one’s own eating and exercise behaviour. Adolescents are asked to keep a detailed record of their food intake, physical activity/inactivity and weight throughout the treatment. They are asked to maintain food logs that incorporate information regarding the type and amount of food eaten per day, calories taken in each food and frequency of specific foods and other eating-related factors such as eating situation, mood, food preferences and availability of food. Similarly, types and amounts of physical activity/inactivity are also recorded in physical activity logs. Activity logs records the structured physical activity (games, exercise routine), unstructured physical activity (walking, climbing stairs, etc.) and physical inactivity in terms sleep duration, number of hours spent on watching television and computer-related activities. They are instructed to record their behaviour daily and bring their self-monitoring logs to the sessions, providing an opportunity for feedback from therapist as well as self.

Objectives of the session

Content of the session

After reviewing the food and activity logs, therapist encourage the adolescent and family to set specific, measurable, achievable, recordable and timed (SMART) goals. Adolescents are encouraged to set clearly defined behavioural goals for the target behaviour identified during assessment. Therapist helps the adolescents and parents to understand that the goal setting is a continuous process and will be continued throughout the treatment.

Goals can be divided into long-term (weight maintenance) and short-term goals. Short terms goals include relatively modest behaviour changes because long-term goals of weight management can take months or years to achieve. Therapist asks the child to set small and specific short-term goals with progressive changes in behaviour (e.g. adding 2 serving of fruit and vegetable in a day and reducing 1 serving of high calorie food/beverages, 15 min of physical activity per day and increase it up to 30 min in a week’s time by adding 5 min each day, reduce television viewing from 4 to 3 h/day then 2 h/day). Setting and achieving these small goals will enhance the feelings of self efficacy in adolescent and increase their motivation for consistent efforts.

Objectives of the sessions

Content of the session

The main objective of behaviour treatment of obesity is lifelong change of unhealthy behaviour. Therefore, behaviour therapist encourages the child to take low calorie food of his/her preference that they can continue to eat for rest of their life and ask them to engage in simple exercise in the form of walking that can be a part of their daily routine. Session 3 focuses upon the lifestyle intervention for the family as a whole. In lifestyle intervention, therapist targets the eating and exercise behaviour of adolescents. With the help of self-monitoring, therapist first identify eating behaviours that lead to weight gain in adolescent and then target them one by one in the process. Eating behaviours that are generally identified in obese adolescents are skipping breakfast/meal, frequent snacking, eating out, eating fast, preferences for junk food and binge eating in response to negative emotional state.

It is well known that eating habits of adolescents are largely a family affair especially in India. Thus, therapist involves parents as active agents to bring a change in their children’s eating behaviour by establishing a healthy lifestyle for the family as a whole. Therapist educates parents about their role in behavioural change and asks them to use following tips to help adolescents in achieving their goals. Parents are asked to keep the handout of the following tips with them and paste it in their most frequent used room.

Objective of the session

Content of the session

Session 4 focuses upon the environmental restructuring by using the technique of stimulus control. It involves controlling stimuli or cues that encourage or maintain the unhealthy behaviour (overeating, eating in absence of hunger and physical inactivity) and at the same time, providing cues that promote necessary lifestyle changes. Adolescents are asked to control stimuli by avoiding high-risk situations such as fast-food restaurants, buffets food, sweets shop and convenience stores. It is assumed that reducing exposure to such situations and problem foods is likely to reduce their consumption. Parents are also involved in the process by asking them to avoid buying and bringing into the home high sugary/high fat snacks, keep tempting items out of sight and serving small portions, as it may help to reduce overeating. Stimulus control is also used to increase physical activity of the adolescents by asking them to keep walking shoes and exercise clothes readily available. Stimulus control is basically based on the problems identified in self-monitoring logs. Therapist helps the adolescent to restructure the environment in such a way that leads to less chances of overeating, e.g. if an adolescent reports that he has a habit of eating a packet of chips/high fat snacks while sitting in front of TV in the evening, then by repeated pairing, this high fat snacks consumption has become associated with watching television. In this case, therapist suggests restricting eating behaviour only on the dining table.

Objectives of the session

Content of the session

It is well known that reinforcement/rewards work well while working with children and adolescents. It becomes easy to change children’s behaviour by using reinforcement or rewards. For obese children, rewards received in terms of social acceptance, wearing smaller size clothes, decreased health risks, compliments from others can be very reinforcing in the early stages of weight loss, but the difficulty of maintaining weight loss suggests that additional positive reinforcement is needed. This module incorporates specific homework assignments with positive reinforcement contingent on successful behavioural change for motivating children. Parents are instructed not to use food as rewards for obese adolescents rather than involving them in pleasant activities such as an evening out, watching movie with friends, a weekend outing, or time spent on a favourite hobby or giving materialistic things such as new clothes and watch can be rewarding for them. Rewards can be decided by adolescent and parents together and should be related to something that encourages positive behaviour, e.g. sporting equipment such as cricket bat, badminton racket and football.