Family Consultation for Change-Resistant Pediatric Obesity

Florencia Lebensohn-Chialvo, MA,Michael J. Rohrbaugh, PhD, Varda Shoham, PhD,

Patricia Lebensohn, MD

Collaborative Family Healthcare Association 13th Annual ConferenceOctober 27-29, 2011 Philadelphia, Pennsylvania U.S.A.

Session #F5COctober 29, 20112:20 PM

Faculty Disclosure

The authors have had no financial relationships relevant to this presentation during the past 12 months.

Need/Practice Gap & Supporting ResourcesWhat is the scientific basis for this talk?

• Pediatric obesity in the U.S. has reached epidemic proportions.

• Although effective treatments exist, many obese children (and their families) do not respond to the psycho-educational programming these interventions usually entail.

• This talk outlines a strategic, team-based family consultation (FAMCON) approach based on family systems principles for cases that do not respond to conventional psycho-educational intervention.

• Although FAMCON appears promising, its application to pediatric obesity awaits systematic evaluation.

Objectives• Describe the dual role of family relationships as (1) a crucial maintenance

factor in pediatric obesity, and (2) a powerful resource for clinical change.

• Highlight the importance of interrupting family patterns that maintain unhealthy child behaviors and promoting communal coping (‘we-ness’) among family members.

• Illustrate applications of the family consultation (FAMCON) intervention format to change-resistant pediatric obesity.

• Describe an approach to improving collaboration between primary care health professionals and family therapists.

Expected Outcome

After the talk, participants will be able to…

• Discuss the relevance of family interaction to pediatric obesity.

• Recognize indications for more intensive, team-based family intervention with pediatric obesity.

• Describe the FAMCON format and clinical procedures in general terms.

• Recognize opportunities for collaboration between primary care professionals and family therapists.

What’s FAMCON?

A family-focused format for resolving health-related problems via communal

coping and strategic pattern interruption.

Other key FAMCON features:• Applied in a stepped-care framework

• Administered by an interdisciplinary team

• Grounded in social cybernetics and structural family systems theory.

• Aims only to alter problem trajectory

• Does not assume change depends on skill acquisition, understanding, or insight.

Key FAMCON Constructs:• Ironic processes

– when ‘solutions’ maintain problems

• Symptom-system fit

– when problems stabilize relationships

• Communal coping

– when ‘we-ness’ helps people change

Rohrbaugh & Shoham (2011), Oxford Handbook of Health Psychology

Problem Solution Problem Solution

More of the same solution leads to more of the same problem, which leads to

more of the solution, and so on.

(positive feedback loop, vicious cycle)

An ironic process occurs…An ironic process occurs…

Ironic Problem-Solution LoopsIronic Problem-Solution Loops

Child misbehaves or shows distress

Child misbehaves or shows distress

Parent distracts or nurtures with food or TV

Parent distracts or nurtures with food or TV

Parent nags, lectures about sugary drinks

Parent nags, lectures about sugary drinks

Child withdraws, sneaks drinks, eats more

Child withdraws, sneaks drinks, eats more

Symptom-System Fit (SSF)…When a problem behavior or “symptom” preserves relationship stability, at least in the short run.

Examples:

– Family rituals centered on unhealthy food preferences or overeating promote positive connections among family members.

– Shared eating habits or eating-related secrets between an obese parent and an obese child mark a cross-generation coalition that detours conflict between parents or occasions disengagement by the other (thin) parent. to disengage.

– Focus on a child’s health problems fosters parental or family cohesion.

Format Overview• FAMCON provides up to 10 ‘consultation’ (not

‘therapy’) sessions over 4-6 months.

• Intervention proceeds through distinct phases:a) preparation (phone contact)b) assessment (2-3 sessions)c) feedback/opinion (1 session)d) follow-up (3-6 sessions)

• Collaboration with primary health care professionals is especially crucial in the referral/preparation, feedback/opinion, and follow-up phases.

The FAMCON team …

a) uses preliminary phone contacts to decide whom to see in what format (preparation phase);

b) conducts a systemic assessment of problem maintaining interactional patterns (e.g., ironic problem-solution loops, weight-based coalitions) via interview, direct observation, and daily diary reports (assessment phase);

The team then …

c) offers feedback in a dramatic, carefully prepared ‘opinion’ session designed to initiate pattern interruption either directly or indirectly and to mobilize communal resources for change (opinion phase); and

d) adjusts intervention strategies to address reluctance and amplify incipient change (follow-up phase).

Assessment Phase Procedures(sessions 1, 2, and sometimes 3)

• Define complaint(s) in behavioral terms• Investigate solution patterns (ironic processes), structural

alignments, and symptom–system fit• Understand clients’ preferred views• Intervene indirectly (e.g., to promote communal coping) with

circular and solution-focused questions• Invite daily diary phone-ins for 14 + days – Track complaint and solution/relationship patterns– Identify patterns of covariation over time, especially

patterns relevant to problem maintenance• [Prepare opinion]

Assessment Modules

1) Customership 2) Diagnostic enactments3) Problem description 4) Solutions and sequences5) Illuminate structure 6) Explanations and preferred views 7) Communal coping8) Family identity exercise

- Solution-focused wrap-up to session 1 - Daily diary begins shortly after session 1- Separate meetings with parents and children in session 2

Daily Diary Procedures12-16 case-specific questions (on 0-10 scales) concerning problem status, patterns of family interaction, and general well-being. For example,

Considering both quantity and quality, to what extent did your child eat in a healthy way yesterday? To what extent did your child engage in healthy exercise behavior yesterday? How much did you attempt to influence your child’s eating or exercise behavior yesterday by ____________ (specify parent ‘solution’ behaviors)?How successful were these attempts?How close and connected were you and your partner (co-parent )yesterday?To what extent did your family (including your child) cooperate and work together yesterday?

Daily Diary (cont.)

•Diary results highlight key problem parameters and family dynamics, as well as agreement/disagreement among family members and trends over time.

•Inter-item correlations, computed over days, show patterns of co-variation both within and between family members.e.g.,

On days when parents work together, child eats in a more healthy way.On days when mom nags and lectures, child is less likely to exercise.

•The team uses selected diary results to seed and reinforce key points in the feedback/opinion session.

• Compliment family strengths and noble intentions.• Frame change as difficult but possible, if family members work together.• Offer reasons to be optimistic based on family strengths.• Review medical recommendations for dietary and exercise regimens.• Present selected diary data to highlight relevant patterns.• Offer direct or indirect suggestions for “less of the same” solutions

(interrupting ironic processes).• Directly or indirectly challenge family patterns the problem helps to

maintain (interrupting symptom–system fit).• Encourage communal problem solving and decision making by “you as

parents” and “you as a family.”• Invite family-level commitment to small but specific changes involving all

family members (e.g., alterations in eating or exercise routines).• [Later, prepare a communication to the PCP about the intervention plan,

including recommendations for how to support it.]

Feedback/Opinion Session

Follow-up Phase Procedures:• Adjust suggestions and tactics according to family’s response

to intervention.

• Introduce enactment modules to interrupt ironic patterns or challenge symptom-system fit.

• Address reluctance and non-adherence strategically (e.g., with reflecting team conversations).

• Nurture and solidify incipient change.

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“HERNANDEZ” FAMILY

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Example of an ironic process:•The more the mother tries to control Alicia’s behavior, the more Alicia acts out, the more her mother tries to control…• e.g. Removing/hiding snacks, demanding Alicia wear her

cpap mask.

Opinion- Interrupting an ironic process:•Suggested a strategic “diagnostic intervention”- asked Alicia’s mother to observe and document her daughter’s behavior when she doesn’t try to intervene.• At the first sign of defiance, mother declares helplessness:

“You know what I’d like you to do, but I realize I can’t make you do it”.

Example of a Symptom-System Fit (SSF):•Alicia’s temper tantrums and sneaking-food behavior keeps grandparents involved- preserving relationship stability.– e.g. Alicia throws temper tantrum because she wants a snack,

mother cannot control her, grandparents step in to defuse situation.

Opinion- Challenging SSF:•Use of frame “a child that is starving for someone to take charge and be firm”.•Mobilize grandparents as a unit to implement mother’s rules and consequences.– e.g. Alicia throws temper tantrum, grandparents help each

other stay firm and implement consequences outlined by mother.

Caveats:•Engaging key family members (including two parent figures) is difficult but crucial – and needs to happen up front.

•Cost-effectiveness is an open question: Although FAMCON is relatively brief, the team approach requires multiple professionals and labor-intensive treatment planning (features perhaps best suited for training settings).

Questions?Discussion?

Session Evaluation

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leaving this session.

Thank you!