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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  1. Roman Korol8:53 am

    The best-laid schemes o' mice an' men gang aft agley (often go askew) as poet Robbie Burns once famously wrote. That applies most especially to well-intentioned interventions of the nanny state because the state has the capacity and incentive to cheerfully expand its interventions on a macro scale with neither limit or logic. Historically the state's interventions have often turned into a horror show, leaving undisturbed or grossly exacerbating the original ills they were meant to address. The Dept of Indian Affairs and Northern Development is a good example. Your intentions are clearly humanitarian but the suggested means to implement them leave to be desired.

  2. Anonymous9:14 am

    You can't fix stupid. There are 1000's of examples of stupid parents doing stupid things towards their kids. Which does the govt step in? vs which they let pass?

  3. I often see eye to eye with you but this is an exception. I know a 13 year old who has always been in the 95-98th percentile of weight (and height, by the way) who is not nor has ever been fat. She is chubby or less; she is fit, she exercises. Should this child be removed by CPS? You know as well as anyone that BMI is an incomplete picture, at best.

  4. Anonymous9:51 am

    If you're aboriginal, if you live in the inner city with access only to the 7-11, if you are a child of previous white do-gooder government intervention into your life through government sanctioned rapes and sexual assaults to make you more like whitey,

    Well I'd say, something that you wouldn't post.

    I think you should ask an aboriginal parent, not your conflict of interest compromised wife.

  5. So we have raging obesity, mostly due to the misguided dietary guidelines of the government (eat low fat, which ends up as high carb), and now the government wants to take children away because they follow the said diet. A travesty . . .

  6. I think it's unfortunate to talk about extreme interventions like removing children from their families when really we should be addressing the circumstances that might give rise to the family's poor nutrition habits in the first place: poverty, lack of education, little to no social supports, lack of affordable, quality child care, diminished public and community health programs, food insecurity.... need I go on? I'd rather see more effort put into addressing the systemic issues so that CAS intervention is not necessary in the first place. Of course, that's unlikely to happen in this political environment. Might as well give mandatory minimum sentences for bad parenting. That'll fix it.

  7. QuietSunshine11:11 am

    This is such a loaded topic.

    I probably was around the 97-99th percentile in weight at times growing up (from 12 years old onwards). I couldn't imagine leaving my parents (I was about 5'5" in high school and 220lbs). My parents were loving and supportive. My mom did try, we went to a dietitian together for one session, but that's all we could afford at the time (and we weren't poor, my mom was a stay at home mom and I had 3 brothers... most benefit plans don't cover registered dietitians). Regardless of that all, I am a university graduate and while I do struggle with my weight (I am recovering from Binge Eating Disorder), I know what I need to do to be healthy and have been a healthy weight that I maintained as an adult (for 4 years, until I had a baby, depression and an eating disorder).

    I would have loved an encompassing program that would have dealt with my fear of exercise (I've overcome that and actually enjoy it), learning good activity habits, self-esteem (was bullied) and nutrition along with healthy eating workshops for my parents and siblings. Yet what resources are available to many families?

    Food, especially nutritious food is expensive. I can buy fresh fruit and veggies weekly with no problem, but I'm in a dual-income household with 1 child. My daughter isn't overweight in the slightest, and we can afford to put her into gymnastics, soccer and swimming. She also goes to school and a daycare with lots of space for running and they both have good play equipment. I often stop by Loblaws on my way to work to buy some things for lunch and I'll buy two apples for say $1.50, at times, they'll have sales on PC chips for less than that and that's not a small bag.

    I am guessing you got the picture for this post from Maury Povich and I agree there are exceptional circumstances such as parents who are deliberately making their kids obese, but I'm guessing those cases are rare (The biggest baby I knew personally had a very health conscious mother who breastfed him exclusively). They also had a case on Dr. Phil (I swear I don't watch much tv) years ago, where a dad got custody of his extremely obese son (the son had been living with his mom, I think this made the news as well) and guess what he lost weight and was much healthier with his dad (seemed mentally healthier too), but I am thinking this may be the exception.

    Access to cheaper produce and whole foods, taxes on junk food, subsidizing gym memberships and fitness programs, dietitian visits, healthy eating cooking workshops and kids activities (I think Ottawa helps lower income families some, but of the three activities I mentioned only 1 is through the city, the other two are through separate organizations) would go a long way before taking bigger kids away from their parents.

  8. I liked that Yoni wrote about how child protective services actually work - there is an assessment process and there are opportunities given to parents to grow and change. These happen prior to an apprehension (except in cases where there is a clear safety concern, such as sexual abuse). These more gray areas - such as physically harming a child through not addressing extreme obesity - are not entered into lightly, and often the case is that they err on the side of keeping the family together.

    Some of the comments make me wonder if the commenters understood that part of the post - intervention is not simply removing the child. Intervention can mean working with the family in a variety of ways. Social workers (and I am one) can talk with families about the problems they are experiencing and try to address the issues, with the families, that are causing the extreme obesity. They can help the families understand nutrition, work with them to have access to professionals who can help them address issues, help them develop the skills to place limits on their children's eating, and help link them to programs to overcome other barriers, such as access to healthy foods, or wage supports.

    Social workers do these kinds of things all the time. Many families are receptive to this, take responsibility, accept the help and their children are never removed, rather family functioning is improved. These aren't the stories that hit the news, but they happen every day.

    Other times, families deny any responsibility, refuse to work with professionals and refuse to change anything. Typically, there is way more going on in those families than just the kids are eating too much, and obesity is a symptom of much larger problems in family functioning, such as addictions and severe mental health issues. That kind of thing may require the kids to be removed for the sake of their physical and psychological health.

    One commenter said we should talk about addressing the circumstances surrounding the child, such as poverty. Agreed. But we are still faced with families who have choices, and when given positive options, and still they choose to make negative choices, sometimes the state has the duty to step in.

    Remember, Yoni is talking about very extreme cases, not every obese child.

  9. That last comment was misapplied to the wrong person. I didn't realize my husband was signed in.

  10. Anonymous2:48 pm

    My daughter as a toddler was in 90's % on the weight-by-height graph given to me by my family doctor. I was concerned. The doctor told me to provide choices of good food and let her decide what to eat. She said "Children naturally eat right. There is no cause for concern"
    I followed her advice.
    Big mistake.
    My daughter was active in sports and dance even though she was heavy (fat, not just big-boned or muscular). She wasn't a couch potato.

    I was very careful to have good food, veggies, lean protein, whole grains, low-fat dairy. I let her eat what she wanted from that selection. I specifically didn't teach her to eat to control her weight because the doctor said NOT to try to control weight because that approach causes eating disorders like anorexia. The doctor said she would naturally lose "baby fat" when she reached puberty - in fact, the opposite happened.

    If I had taught her to eat to manage her weight, she would have learned early - now she's in her 20's and playing catch up.

    I used to think my friends who taught their children to eat to watch their weight were wrong. Now I wish I'd done the same. I did my daughter a great disservice, even though I was just trying to follow my doctor's advice.

    If it's bad for parents to cause obesity in a child, it's absolutely criminal for a doctor to ignore a clear warning, (that 90+% weigh/height), and to give advice which worsened my daughter's problem.

    My 2 sons did fine - they were always normal weight, normal weight/height ratio, with that approach to food. I - and the DOCTOR - should have recognized that my daughter needed a different approach.

    If you want to improve child weight & health through public services, you could help the medical profession get its act together. Preventing obesity is best. More parents see doctors for routine checkups than see Children's Aid. By the time children's aid is involved things are in crisis already.

  11. essbee4:02 pm

    I'm really quite surprised at your position, Dr. Freedhoff. Generally you're so averse to blaming the individual for obesity - it's the environment, you emphasize, that needs to be fixed. It's not (simply) that individuals lack the discipline to consume fewer calories than they expend...our culture itself is obesogenic.

    So I really find it odd that you're pro blaming the parents. Why is it that when interventions fail with adult patients you're willing to continue to blame the environment but when interventions fail with parents it's all of a sudden the individuals' fault? I'm not trying to sound combative - frankly, I agree that the only way to successfully combat obesity is to change our culture drastically - I'm genuinely curious where you're drawing this line. Is it because the parents' behavior is affecting a child, who cannot make decisions for him- or herself? So even though the environment is to blame, because the individual failure to overcome it affects another person, it's time to move ahead with more drastic measures?

    If the environment doesn't change, and physician interventions (for instance) haven't succeeded with the parents, what is it about child protective services interventions (short of removing the child from the home) will achieve? Are CPS interventions so much more effective than physician interventions? Are CPS organizations so much better staffed that they can bring more resources to bear on the problem in any given home? That has not been my experience...perhaps your wife's experience differed.

    I'm not convinced that CPS interventions in these cases won't either fail just as much as other interventions, or do more harm than good.

  12. I think we should all re-read Miss Vickie's comments, which are spot on.

    I believe that extreme overweight often has a lot more to do with the social determinants of health than anything else. Food choices are based on education, income, emotional and physical health, etc.--in short a host of factors that must be dealt with rather than removing a child from his or her home.

    When I was about 6 or 7, I spent two weeks in a foster family because my mother had to have an operation and then required some time in the hospital to recover. My parents were long separated and there were no other family members to look after me. This was a temporary separation, which had nothing to do with my mother's parenting skills. Although it only lasted two weeks, and though it's been over forty years since it happened, I still remember how horribly the family treated me and how miserable and frightened I was. For me, it felt like twenty years, not two weeks. I can't imagine the horrors of the residential school system...The psychological effects of taking a child out of the family can be devastating.

    We must tread EXTREMELY carefully in this area. Robert Burns was right about the best laid plans.

    And BTW, I am a certifed left-of-centre, "taxes and state intervention are good" kinda gal.

  13. Essbee,

    Offering help to parents to combat such things as environmental determinants of weight is anything but extreme.

    Apprehension of a child consequent to their weight would be an exceedingly rare event, however recognizing their extreme obesity as a risk (remember, the cutoff the authors' proposed was 99th percentile and above), would allow the family and child to then receive supports and education which in turn might help.

    Nothing wrong with hoping for physicians to help. The role of CPS though would be to marshal resources.


    I don't think Miss Vickie's notes are spot on. The editorial recommends apprehension in the most extreme of circumstances, and if and only if marshaled resources failed to help.

    Where we do all agree is the need to tread exceedingly carefully. By creating a national discussion on the matter, what I hope to see is in fact protocols and plans in place to ensure that cases are evaluated gently, carefully, and properly so as to reduce the risk of ill-prepared or ill-informed CPS workers causing more harm than good.

    Where I see there being risk is denying the risks inherent to severe obesity due to worries about CPS/foster care. To me they're two separate issue.

    As a physician, were I to suspect risk to a child of any sort, my duty (my actual legal obligation) is to report. What the editorial is suggesting, is that severe cases of obesity carry sufficient risk to the child as to make it society's obligation to muster resources to help that family. If the CPS/foster case system is broken then indeed, that's horrible and needs attention and fixing, but it doesn't take the onus off our job in society to try to protect its most vulnerable members.

  14. The adult population first must realize the real nutrition facts, corruption and prostitution in the nutrition industry and then change at the personal level can start. Do not expect kids to change if you cannot sell the change to the adults. Good luck with that.

    First, the "state" would need to understand "good nutrition". Look at the Canada good food guide to understand how good the state is at that, and compare that to something like Mark's Daily Apple Primal.

    Secondly, recognize that foster care is primarily to provide safe physical space, and does nothing to educated the children, which is what is primarily required, along with, consistent provision of suitable foods supply, and consistent demonstration of good eating habits.

    If at least these basic factors and not there, good luck. Children do not learn well by lecture, and leave. Example is required to form habit.

    The nutrition industry need to have consistent correct information, not just sales pitches for there products.

    This is just opinion, not facts.

  15. Anonymous7:32 pm

    The extreme intervention (removal from home) is directed towards extreme cases (neglect/abuse), and the majority of obese children would most likely not fit into this 'extreme' category. The authors even write that "state intervention would clearly not be desirable or practical, and probably not legally justifiable, for most of the approximately 2 million" obese children in the US.

    Having read the article myself, it points out how modern society promotes unhealthful lifestyles in children. These children may or may not be in a situation of neglect or abuse. So the authors want to consider the possibility of alternative methods to treat obese children.

    The editorial discusses that there is potential harm for obesity-related chronic disease in later life including type II diabetes, and that poor outcomes of conventional treatment is now, for some children, leading them to be considered for bariatric surgery-- of which the long-term outcomes and complications are not well known. So, the ultimate question is, "are legal considerations an alternative therapeutic approach?"

    Murtagh and Ludwig note in their editorial that state intervention may serve the best interests of many, and that child protective services typically provide intermediate options such as in-home social support, parent training, counseling, and financial assistance. In severe cases, this support may not be enough; however, it sounds to me that intermediate options would be the first step. The authors go on to mention that home-based behavioral interventions have proven unsuccessful at times.

    In conclusion, they reason that state protective services might be considered an option. And foster care placement considered in carefully selected situations.

    The very last sentence points out the urgency for government to reduce the need for such interventions by reframing the social infrastructure and policies to improve diet and lifestyle.

    I think many would benefit from reading the actual editorial.

    Also noted that the first sentence of the editorial states, "Many biological, psychosocial, and behavioral factors affect energy balance and, therefore, child weight gain..."

  16. Anonymous10:57 pm

    Want to make a bigger mess of the mess you already have?... Get the govt involved. Geeze people... have we NOT learned yet???!!!

  17. I can't get past the fact that you decided to use headless fatty pics, and of children. These children are people, and using the picture in such a casual fashion objectifies them and contributes to the bullying and shaming of fat people. I'm pretty sure that isn't your intent, but it is what it projects.

    What happens if the parents follow the measures prescribed and the child remains obese? I'm all for education, fresh food and exercise, but sometimes obesity remains in spite of that. This implies that we know all there is to know about obesity, and if all else fails, then the parents are child abusers. Ugh.

  18. As long as child protective services takes action in the far greater percentage of cases in which children have eating disorders that do not necessarily lead to obesity, I might start talking about such proposals seriously.

    However, considering the lack of funding given to such child protective services and the dismal state of foster care of similar alternatives, I have to ask: 1) where will these children be placed? and2) where will the funding for such measures come from? Or, as usual, hasn't anyone thought that far?

    You know all those stories in the news about terrible things happening to children in foster care? I know quite well that there are good, dedicated parents in the foster system (I've been a respite care provider myself because I've known some of them), but those stories are quite real because there are also some very bad people who slip through the cracks, and social workers have far, far more cases to supervise than any human being could possibly keep up with - certainly more than their own departmental guidelines permit. However, due to lack of funding, they have to deal with it. One investigation after another has shown that mandated welfare checks on children just don't happen, and children end up dying as a result. Obesity according to an insurer's chart or death due to neglect or overt child abuse - which is better? As a parent, I know which I would choose.

    Even if that system were healthy and had plenty of funding and available, marvelous people ready to take care of every child, it is ludicrous to take children away from their parents when it has been proven by one study after another that "eat less and exercise more" simply does not work for many people!

  19. Anonymous11:27 am

    The miracle wight loss solution is now Foster Care!!! Who knew? Put me in foster care, I'll try it!
    How hard did you bang your head doctor?
    If there was ever a clear admission by the medical community that it has nothing to offer in the way of treatment for obesity, this is it. You and your peers have reconfirmed my low opinion of your medical abilities in dealing with obesity.

  20. Anonymous7:35 pm

    Removing a child from their home is always a last resort, especially in a case of obesity. Many may just as well be overweight, despite a parents efforts to feed them nutritious foods, and keep them active. But these are not the cases that would be considered, and are certainly not what these articles are discussing. I work in a daycare where two overweight parents feed their slightly overweight two-year old girl practically nothing but junk food. (skittles for breakfast, junk for lunch & snack, followed by cookies and a promise of more candy after arriving home after 6) There is not mention of dinner. This is pure laziness & stupidity that is slowly killing her. Her doctor told them she was overweight ( they admitted it!) but they don't see it and have continued with the same food habits since. She is also completely out of hand in terms of behavior and they use food to suck up to her. It makes me want to vomit and kick both parents in the a** all at once. Something needs to be done; whatever, whoever gets it done, it really doesn't matter!