Childhood obesity is one of the major public health challenges of the 21st century (World Health Organization, 2021). In the world, around 42 million children under the age of five are estimated to be overweight or obese, and the prevalence is still increasing. It has been calculated that, by 2025, about 70 million children will be overweight or obese (Ng et al., 2014). Among European countries, Italy shows one of the highest rates of excess weight among school-aged children, with 20.4% of children with overweight and 9.4% with obesity (World Health Organization, 2017). Children with obesity demonstrate an increased risk of remaining obese in adulthood (Simmonds et al., 2016). In addition, childhood obesity is associated with cardiovascular, respiratory, and metabolic diseases, hypertension, cancer and early mortality in adulthood (Weihrauch-Blüher et al., 2019). As far as mental health is concerned, adolescent obesity is associated with many comorbidities (Drosopoulou et al., 2021; Kokka et al., 2023), including depression (Sutaria et al., 2019), anxiety, low self-esteem, poor quality of life, body dissatisfaction, and other emotional and behavioral problems (Griffiths et al., 2011; Rankin et al., 2016). Significant associations were also found between obesity and attention-deficit/hyperactivity disorder (ADHD) (Erhart et al., 2012; Khalife et al., 2014) and conduct problems (Nujić et al., 2021). Additional findings (Marks et al., 2009) showed that obesity is associated with many psychosocial problems such as stigma, teasing, and bullying. Such psychological conditions are pervasive and can have serious consequences for emotional and physical health.

Adolescence is a particularly high-risk time for weight gain due to the naturally occurring metabolic changes of puberty, but obese children have been found to gain more weight than their normal-weight peers (Jasik and Lustig, 2008). In addition, many studies confirm that overweight and obesity in childhood can influence early puberty, mainly in females (Polat, 2022). In a recent study, earlier pubertal timing was associated with several psychological distress and behavioral problems, such as more alcohol, nicotine, and cannabis use, more risky behavior, emotional distress, greater likelihood of being bullied, and more symptoms of major depressive disorder, and adult antisocial behavior (Padrutt et al., 2023).

The psychological functioning of children and adolescents with obesity can be investigated with a range of assessment tools, including the Strengths and Difficulties Questionnaire (SDQ; Goodman, 1997). Although SDQ is one of the most used instruments to assess the psychological adjustment of children and youth only few articles have been published about the psychological profile of children and adolescents with obesity via SDQ (Griffiths and Page, 2008; Beynon, 2023; Donnchadha et al., 2023), and none of them were carried out in the Italian context.

Thus, the current study aims to assess the psychological profile of a sample of Italian adolescents with obesity, via SDQ, addressing their social, emotional, and behavioral functioning. Specifically, any potential differences between genders as well as degrees rates of obesity were assessed.

The sample was composed of 114 consecutive Italian adolescents with obesity (43 males, 71 females), aged between 11 and 17, mean age 15.1 (SD = 1.66), mean body mass index (BMI ± SD: 37.4 ± 6.13 kg/m²), seeking a 3-week period of hospitalization for a multidisciplinary body weight reduction program. Most of the sample completed middle school (80%), lived in the Northern regions of Italy (74%) in families with low-to-median socio-economic status (68%).

We analyzed the scores of SDQ from a qualitative and then a quantitative point of view.

In this research, we evaluated the psychological profile of a sample of Italian children and adolescents with obesity, seeking an in-hospital multidisciplinary body weight reduction program, via SDQ.

Taking a qualitative perspective, we found several indicators of psychological concerns in children/adolescents with obesity, as shown by an “abnormal” impact score of SDQ, indicating how heavy the impact of difficulties that these subjects experienced in many life domains is. Accordingly, several findings in the literature suggest that the condition of obesity can severely impact the psychological and social adjustment (Griffiths and Page, 2008; Pulgarón, 2013; Erskine et al., 2015; Beltrán-Garrayo et al., 2023). Literature also suggests that the condition of childhood obesity is linked to some psychosocial disadvantages such as parental divorce (Hamer and Stamatakis, 2008; Gundersen et al., 2011) and low family income (Hanson and Chen, 2007).

In light of our results, peer relationships seem to be one of the impaired areas in the mental functioning of Italian adolescents with obesity seeking an in-hospital multidisciplinary body weight reduction program. Young subjects suffering from obesity are often subjects of stigma and victimization. Weight stigma in youth occurs most frequently in the form of teasing and bullying from peers about body weight. For youth, experiences of weight stigma can be particularly damaging, with long-lasting consequences that negatively affect their life course emotional and physical wellbeing (Puhl and Lessard, 2020). In some studies of the literature, girls have been found to experience more weight stigma when compared to boys (Salmon et al., 2018) and related negative consequences on mental health (Juvonen et al., 2019). Signs of low mean scores of emotional wellbeing in females emerged also in our study. SDQ revealed a “borderline” score of total difficulties and emotional symptoms in young girls suggesting a quite clinically relevant impairment in their emotional wellbeing.

Even assuming a quantitative approach and exploring differences between genders in all the dimensions of SDQ, we found consistent results that showed greater levels of emotional symptoms and peer problems as well as total difficulties and the total impact of females than males. Such results are independent of the degree of obesity, as shown by comparable values of SDQ items between the two subgroups (group 1: BMI SDS 2-2.99 vs. group 2: BMI SDS > 3). Consistently with our results, large differences between genders have been detected in this domain across literature, as suggested by numerous studies in which females were more likely to show worse psychological conditions than males, including emotional problems such as depression and anxiety (Phillips et al., 2012).

Our results also showed significantly higher scores in pro-social behaviors in females than in males, this finding being in line with the literature, where girls were found to report greater levels of pro-social behavior than boys (Carlo et al., 2007). It is worth noting that, in our study, negative associations between pro-social behaviors and conduct problems as well as peer problems were found, suggesting that the higher the level of pro-social behavior the lower the level of conduct and peer problems. Such evidence leads us to read pro-social behavior as a potentially protective factor against the onset of problematic psychological functioning but, further investigation in this direction is required.

The current study presents some strengths. It is one of the few attempts to investigate the psychological functioning of children/adolescents with obesity using SDQ in the Italian context. In addition, it has been carried out in a highly specialized clinical center for obesity that allows us to reach a sample of a specific and clinically relevant population of children and adolescents with a high degree of obesity.

However, some limitations of the study need to be pointed out. First, the cross-sectional nature of the study with a lack of comparison with a control group of normal-weight peers and no longitudinal measures prevented us from leading causal conclusions. Second, the use of only a self-report measure for psychological adjustment carried out a risk for biases and so, required caution in the interpretation of the data. Third, the sample was recruited from a single clinical center in Italian adolescents with obesity seeking an in-hospital multidisciplinary body weight reduction program and, thus, could be scarcely representative of the entire population.

Despite the above limitations, the present study provides evidence for several difficulties in the psychological adjustment in adolescents with obesity. In summary, a high prevalence of “abnormal scores” in the total impact score, emotional problems, and peer problems was found, with less than 50% of female participants being in the normal range.

We also found that higher emotional symptoms and peer problems as well as total difficulties and the total impact scores were reported by females in comparison with males, and peer problems seem to be one of the most impaired area in the mental functioning of obese adolescents. Furthermore, no significant differences were found between the two BMI subgroups.

Such evidence can be useful to understand the psychological condition of adolescents with obesity in a better way, and, concurrently, develop effective interventions for the treatment of pediatric obesity which not only take into account the medical and physical aspects but also the emotional and social difficulties expressed by adolescents with obesity.

Nevertheless, further effort is required to explore the extent and implications of psychological impairment in adolescent obesity to deeply understand the phenomenon as well as to provide efficient interventions. Future directions of the study toward collecting additional data about family and economic conditions of adolescents with obesity should be depicted to deeply understand the impact of psychosocial factors on adolescents with obesity development.

The raw data supporting the conclusions of this article will be made available by the authors, without undue reservation.

The current study was approved by the Ethical Committee of Istituto Auxologico Italiano, IRCCS, Milan, Italy (approval number: 2021_01_26_03). The studies were conducted in accordance with the local legislation and institutional requirements. Written informed consent for participation in this study was provided by the participants’ legal guardians/next of kin.

AG and AS: conceptualization. AG: formal analysis and writing—original draft preparation. MB, GM, DC, and NM: data curation. GC and AS: writing—review and editing and supervision. All authors have read and agreed to the published version of the manuscript.