Methods Evaluation of referrals of families referred to Tier 3 obesity service for children 4–12 years with BMI > 98^th centile (or 91^st centile with complexity), previously unengaged. Project ethos based in principles of systemic family psychotherapy, approached the problem following NICE 2013 guideline Childhood Obesity. Family therapist, dietician, activities specialist and paediatrician, offered a comprehensive outreach approach including home visits. Initial assessment explored causes and complications of obesity including Strengths and Difficulties questionnaire SDQ and assessment of child’s mental health. Goals were set with families including parenting/family therapy. Families were seen fortnightly for 3 months, assessed 3 monthly, up to 1 year.

Results 144 referred: School Nursing Team (71); Community Paediatricians (37); Others (36). 120/144 (83%) met criteria for clinic. Of these 72/120(60%) accepted first appointment (no response from 20/120(16%), declined by 28/120(23%)) Ethnicity of children: White 19%, Black British/African/Caribbean 60%, Other 20%. English as additional language 33/72(46%), 9 requiring interpreter. All were >98 <sup style="font-family: Arial, sans-serif;" >th centile BMI. Almost all children engaged stabilised BMI z scores at 3 months. (20/23 (87%).

Frequent psychosocial factors identified includied lone parent 27/72(38%); siblings/parent physically disabled;12/72(17%); no parent employed 17/72(24%), current/previous social services 12/72(17%), domestic violence 9/72(13%), parental mental illhealth:8/72(11%). Neurodevelopmental disorders included autism, Down’s syndrome, ADHD, Cerebral palsy, learning disability and medical problems, plus significant behavioural difficulties.

Initial SDQ indicated substantial risk of clinical significance 19/72(26%). Two children were suicidal and self harm concerns in four. Referrals were made to social services for CIN or CP concerns (12/72) (17%).

Conclusion Extreme obesity in children is systemic and multifactorial, often associated with concerning psychosocial problems in families. Paediatricians who care for children who are extremely obese should enquire about mental health, parenting, development and psychosocial factors, and make appropriate referrals. Childhood obesity often indicates family distress and unmet need including important child mental health difficulties.