Thursday, July 14, 2011

Can childhood obesity warrant child protective services?

That's what an editorial published in this week's JAMA, written by Lindsey Murtagh and David Ludwig states.

The main stream media is painting the authors' suggestion as alarming and extreme, but reading the actual editorial, I'd argue it's anything but.

The authors weren't writing about removing kids in homes with excessive junk food and XBOXs, and a few pounds that some chart or physician might suggest they ought to lose. The authors were writing about "severe pediatric obesity", which they defined as a BMI beyond the 99th percentile, and where interventions designed to help those kids' parents failed to help their children.

The authors argue that extreme pediatric obesity can be life threatening, that it can cause immediate and potentially irreversible medical complications, and that it can markedly shorten life expectancy. Surprisingly, not mentioned by the authors is the psychosocial impact of severe obesity on children, where studies have documented terrible bullying and stigmatization which in turn impact on a child's mental health and education.

According to American federal laws child abuse and neglect are defined as,

"any recent act or failure to act on the part of a parent or caretaker, which results in death, serious physical or emotional harm ... or an act or failure to act which presents an imminent risk of serious harm"
The authors estimate that for a child to be in the 99th or higher percentile for weight that they are likely consuming a minimum of 1,000 more calories per day. Put in some perspective, that would be the equivalent of 2-3 additional meals worth of calories daily.

To look at the issue of child protection broadly, for me, as a father, as physician and a member of society, if there's a family actively engaging in any behaviour that can dramatically and potentially permanently harm their child, and if with counselling and intervention they don't modify that behaviour, then yes, I think state intervention is appropriate.

To discuss this properly though, people need to understand what state intervention means, and what I gather from the press reports and their online commentators is that people don't understand how the system works. People don't seem to appreciate that the path from a visit from a child welfare organization, to a child's removal from that home, except in the case of suspected sexual or physical abuse, is not a rapid process.

I checked with my wife who used to work for the Children's Aid Society as a child protection worker, and according to her, in the case of obesity what this would entail would be starting with interviews and medical testing and evaluations to rule out any medical conditions that may be impacting on weight, or any other factors outside of parental control, followed by parental education and family visits with pediatric obesity teams and specialists, followed by regular visits and weigh-ins to assess impact. If the child in question continued to rapidly gain there may then be a circumstance where the child is placed temporarily in foster care and weight measured outside the home environment. If the child lost or maintained weight in foster care, that would bolster the case for there needing to be a change at home. If after what would almost certainly amount to more months of education and effort there were still no improvement, only then would there be the possibility of a more permanent removal.

Society wouldn't hesitate to address undernourishment as a risk worthy of state intervention. Given extreme overnourishment is a tremendous risk as well, why shouldn't severe childhood obesity be a child welfare concern?

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