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Wednesday, July 21, 2010

Hot Issue: Childhood Obesity and Parental Neglect

obese children

BananaStock

As I was perusing my weekly stack of new news in research, I came across a recent study published in the British Medical Journal by Russell Viner at the UCL Institute of Child Health, London, England. The title caught my eye: “Childhood Protection and Obesity: Framework for Practice“. I know that my colleagues across the pond have been quite aggressive about finding creative solutions for countering the childhood obesity epidemic in England. Their Academy of Pediatrics has recently proposed a ban on junk food and beverage TV ads aimed at kids, a stiff tax on sugary items, and a requirement that fast food restaurants be located far away from schools. But this BMJ analysis takes the discussion to a different and understandably more contentious place. Should parents be blamed for their child’s obesity? Intrigued, I did some homework to share with you.

The childhood obesity-child protection issue has emerged over the past several years, garnering increased media and professional attention. At the 2007 British Medical Association’s annual meeting, members rejected a motion in which obesity occurring in kids under 12 constituted a reason to charge parents with neglect and removal of the child into protective custody. This action followed on the heels of a BBC survey of 50 pediatricians who noted that childhood obesity had been a factor in at least 20 child protection cases in 2006. The UK is not alone in its concerns, which are evident internationally, including US courts which have already been removing some obese children from parents considered neglectful. Here’s an example from Missouri, where an boy was removed from his foster home because his foster father was obese.

The BMJ authors examined the existing literature on childhood obesity and protective actions and suggested a blueprint for action. What they found is that there is indeed evidence of an association between obesity and sexual abuse, violence and neglect. However, there is no data on the relationship between child protection actions and weight control in the long term. Moreover, there’s no information about the long term physical and mental welfare of an obese child who undergoes removal from the home and placement into foster care. This lack of evidence led the authors to note that it’s not reasonable to propose that legal actions are warranted for the existence of obesity or the failure to control it. Here’s what they wrote:

The aetiology of obesity is so complex that we believe it is untenable to institute child protection actions relating parental neglect to the cause of their child’s obesity” or “to criticize parents for failing to treat it successfully, if they engage adequately with treatment”.

Note the “if they engage” clause. Would legal intervention follow if they didn’t? And what constituted “adequately”?

The BMJ authors note that obesity is part of a larger constellation of child welfare concerns related to child protection. This means that all aspects of the child’s family and living environment, including nutrition and activity, need to be closely assessed when determining what’s best for the child’s welfare. The authors note, “a family with an obese child should not raise child protection concerns if obesity is the only cause for concern” but “clinicians should be mindful of the possible role of abuse or neglect in contributing to obesity.” To further complicate things, there is good research that shows even when obese children have strong family support or ready access to credible weight-loss programs, kids can still struggle to remove the pounds.

On the other hand, they also noted that parental neglect does exist when there is a consistent failure to implement healthy lifestyle changes, or if there is a refusal on the part of parents to accept assistance from weight management programs and professionals. This is especially true in the case of obese kids who are already suffering significant problems related to their obesity, including high blood pressure, type 2 diabetes, sleep apnea, high cholesterol, or physical disabilities leading to decreased mobility.

Further, the researchers note that “parental failure to provide their children with adequate treatment for a chronic illness (asthma, diabetes, epilepsy, etc) is a well accepted reason for a child protection registration for neglect“. They suggest that failure to comply with obesity treatment (missing appointments, not supporting obese children with weight management programs or even actively sabotaging their kid’s efforts) is tantamount to neglect, especially in those kids who are already suffering medical consequences arising from their obesity. The authors stressed that “Clear objective evidence of this behavior over a sustained period is required, and the treatment offered must have been adequate and evidence based.” And all medical providers are being called to task to pay attention to the red flags of parental neglect, including the need to “evaluate other aspects of the child’s health and well being and determine if concerns are shared by others professionals such as the family general practitioner or education services.

At the conclusion of the study, the researchers noted:

As in all areas of child health, we have a duty to be open to the possibility of child neglect or abuse in any form. When assessing such children, a comprehensive picture of the child’s functioning from a health, psychological, and educational perspective is necessary. Guidelines for professionals are urgently needed, as is further research on the outcomes of child protection actions in obesity and links between early adversity and later obesity.”

In reviewing the media coverage on this topic, it’s clear that the Brits are more open to aggressive legal actions, especially for children under 12. They see it as an issue of “extreme overfeeding”, which, they believe, constitutes abuse. They argue that malnutrition and starvation of a child results in immediate court interventions, so why not obesity? But the Royal College of Paediatrics and Child Health has continued to argue that obesity is a public health problem, not a child protection issue. Internet commentary from UK citizens runs the gamut from:

“These are totally correct decisions by the social services. Parents who insist on stuffing their children with junk food are not just ruining their childhoods, they are set on ruining their lives by instilling habits they may never be able to shake off. It is an ill recognized form of abuse but that is what it is. Obesity is just the most obvious form of neglect, there are probably many more going on simultaneously with each kid. Parents like that aren’t worth hanging on to anyway. I should know – my mum was one of them. - Bob Grant, London, 14/6/2007 10:38

To this one:

Let us be fair about this. Under this government, councils have sold off playing fields restricting the places children can safely play. Despite the efforts of Jamie Oliver, school meals are just plain rubbish. Health and Safety ‘experts’ are destroying childhood with their petty rules and regulations. Junk food manufacturers are aiming the adverts at children before the watershed. Fast food is loaded with fat and sugar. And now this same government wants to penalize parents for their children being overweight. This whole scenario stinks of corruption and another NU Labor scheme to rule peoples’ lives. Big brother and the nanny state isn’t half of it. - Rc, Scotland, 14/6/2007 14:54

I looked at comments posted under the Washington Post‘s Check Up blog written by Jennifer Huget and found:

The idea that a child would be removed from their family because of obesity issues is another example of the ostracizing of obese children. Ostracized at school, in extra-curricular activities, in the media, in public places, it would be abusive to remove them from loving families. They would feel even worse about themselves. I cannot believe there is any cause for such a discussion! Obesity is complex, and foster care has certainly not “worked” for children who are abused! Posted by: lydandy | July 19, 2010 11:11 AM

As well as:

While I do not at all believe that a child’s obesity should be a sole cause for removal from his or her parents, I do believe that allowing one’s child to become obese is a form of neglect or even abuse – just as is allowing one’s child to suffer from malnutrition. Many children in my family are obese (we are not genetically disposed) and I just had a discussion about this with another family member over the weekend. We talked about the fact that it is a parent’s responsibility to keep a child safe from harm, to keep them healthy and to help them form good habits – whether it be teeth brushing, hand washing or choosing healthy snacks – and that somehow the responsibility for teaching reasonable eating has fallen by the wayside with certain parents in our own family and around the country.I agree that there are other factors involved such as horrendously unhealthful school lunches, the comparative costs of healthy, fresh foods and unhealthy, processed foods, etc. I also agree that it is no comment on how much these parents love their children. But ultimately, the parent is the adult – the one who brings the food into the home and purchases it when a family eats out. A parent is also a child’s first and most important role model and has almost total control over what goes into that child’s body for the first several years. In my eyes, the bulk of the responsibility for this epidemic lies squarely on the shoulders of the parents. Posted by: MrsDre | July 19, 2010 1:00 PM |

Finally, in my search for the best overall analysis on the childhood obesity-parental neglect topic, I found this article from Pediatrics, the journal of the American Pediatric Association. It’s entitled “Childhood Obesity and Medical Neglect” by lead author Todd Varness MD, MPH from the Departments of Pediatrics and Bioethics at the University of Wisconsin School of Medicine and Public Health. I felt it was one of the most comprehensive summaries available and well worth a read. Here’s the bottom line on the question “Does childhood obesity ever constitute medical neglect?” The authors answer by noting that there are 3 criteria that must be met to justify governmental intervention, including:

  1. a high likelihood of serious imminent harm;
  2. a reasonable likelihood that coercive state intervention will result in effective treatment;
  3. the absence of alternative options to address the problem.

The bottom line is that this is a very complex and controversial issue. Even the vernacular is challenging. The word “neglect” is a necessary legal term, but it infers moral judgment about the parents. The real goal is to protect children from serious harm. Most pediatricians have gone on record noting that the majority of parents do care about their children, but may not be knowledgeable about how to do it.

Perhaps the very media exposure this issue is providing can be a wake-up call to all parents to take this issue much more seriously and see out the help they need. Print, radio, TV and online multimedia messaging can open parents’ eyes. That means that every parent must be a role model for their children by walking the talk and creating a healthy living environment for the whole family. This is a potentially huge win-win. Doctors and all medical care providers are also role models and mentors who need to provide counseling, education and programs for parents to help obese children and their families. I see this issue as a call to arms to team effectively across many disciplines to do what is right — protect a child’s health and well being.

Share your thoughts about this on my Diet Community discussion group entitled: Does Childhood Obesity Constitute Parental Neglect?

Posted by: Pamela Peeke, MD at 2:28 pm

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