Childhood Obesity and Medical Neglect

In an interesting intersection of my interests in food and foster parenting, there's an emergent tendency to view extreme childhood obesity as a problem of medical neglect. Medical neglect can be grounds for removing children from their home and placing them in foster care, as seen in this recent case in Ohio:

An Ohio third-grader who weighs more than 200 pounds has been taken from his family and placed into foster care after county social workers said his mother wasn't doing enough to control his weight.

The Plain Dealer reports that the Cleveland 8-year-old is considered severely obese and at risk for such diseases as diabetes and hypertension.

Medical neglect is a common reason for removing children into foster care - when a parent shows a consistent inability to meet a child's medical needs, whether physical, mental health or other, children can be removed from their home. One of our potential placements that fell through was a medical neglect case with children who had never seen a doctor and a case in which two were severely malnourished, probably due to untreated medical conditions.

Such removals for obesity are still comparatively uncommon, but there is an emergent trend to respond to intractable cases of severe obesity by removing children from the home. As a 2009 article in Pediatrics observes, doctors are beginning to agree that given certain grounds, severe obesity consitutes a form of medical neglect when:

(1) a high likelihood that serious imminent harm will occur; (2) a reasonable likelihood that coercive state intervention will result in effective treatment; and (3) the absence of alternative options for addressing the problem. It is not the mere presence or degree of obesity but rather the presence of comorbid conditions that is critical for the determination of serious imminent harm. All 3 criteria are met in very limited cases, that is, the subset of obese children who have serious comorbid conditions and for whom all alternative options have been exhausted.

It isn't clear whether the Ohio case meets these criteria, and it is dangerous to judge without information (among other issues, there are a few rare genetic disorders that prevent children from ever feeling full, leading to obesity and other medical conditions that might be factors), there is an emergent tendency for courts to intervene in severe cases of childhood obesity. Sometimes the courts order parental actions like gym memberships and nutritional classes. in other cases, kids are removed from the home.

In our foster parent training, there was exactly zero attention paid to issues of nutrition and food for children, or for that matter, much of any medical issues. The working assumption was that foster parents would research and train themselves, or at best be given a few hours of show and tell on how to handle a wide variety of potentially serious medical needs - from handling catheters to feeding malnourished infants in failure to thrive cases, to nursing babies through withdrawal in cases of prenatal drug exposure to handling serious psychiatric disorders. Food didn't even enter into it - and the worker seemed totally unaware of food issues.

The more common scenario for children in care is that they have not been sufficiently fed - many steal or hoard food, saving it so that they will always have some, since food was an irregular item in their lives, but many foster parents are seeing an increasing number of overweight children. That partly mirrors the culture at large, of course, but also can be contributed to by a number of factors of poverty, including:

1. Parents who work long hours and are not present to control eating habits

2. Parents who use food to medicate or control or distract their children

3. Depressed children who eat to manage intractable emotions due to experience, or who mimic adult habits of overeating.

4. The high cost of many healthier foods leading to houses full of high calorie junk

5. Lack of knowledge about good nutritional choices, endemic in our society.

6. Living in food deserts without easy access to healthy food

7. Lack of safety in nearby outdoor areas that mean children cannot safely leave their homes to get exercise

8. Living on food stamps and having to shop mostly at convenience stores that will illegally trade in food stamps to allow families to get things not covered by food stamps like toilet paper and soap - these stores have a poor selection. The same stores often are the only ones that allow credit to poor families when they get to the end of the month and have little or no food at all.

9. TV and video games as the only babysitters and entertainment.

10. Lack of access to kitchens - many shelters and motels have no access to any way to cook any food, leaving people to live mostly on processed items.

11. WIC programs that encourage and support the feeding of calorically dense foods like peanut butter and whole milk to young children, regardless of their weight.

12. Severe parental obesity, having both genetic and lifestyle components.

Without giving parents a pass, it is worth noting that a number of cultural factors affect chidhood obesity and that poor and struggling parents are probably more vulnerable to these factors than the average. Moreover, if my county's training is any example, a move to a foster home may not mean better nutrition or more nutritional education. Remarkably, most of the foster parents I know do manage to meet the medical needs of the kids in their care, often learning fast and hard how to handle seizures or leg braces or burn care - but weight issues are hard and particularly hard in children, and nothing has prepared us to handle these.

We had a difficult time getting certified, in part because one of the workers had no familiarity with farms, and felt that our house ought to meet certain suburban standards that are simply impossible to do in a rural setting. The end results were fine, and we worked it out with the worker's supervisor, but the framing of this issue was concerns about allergies and asthma. These are legitimate (our second placement involved a child who didn't tell social workers about his asthma and cat allergies before coming to our home) reasons to have that concern (although I don't think particularly more than any suburban house with pets), but it struck me when this came up how little the county was concerned with other safety and health issues, including obesity and household chemical use, both of which are just as implicated in childhood health. It wasn't that I didn't take their concerns seriously, but I was struck by the complete absence of concern about other issues.

It seems pretty clear that for children who are severely obese, the best outcomes requires that some response be made. My hope is that counties will try and work with parents first, before adding the emotional trauma of family loss. As the Child Welfare League points out, the first steps should be making sure that underlying medical and mental health conditions are addressed, that families receive services and support and that they understand the very basic concepts of nutrition:

Courts should look at whether the state has provided the family with intensive, family-oriented services including: family counseling, education regarding proper nutrition and exercise, income supports, menu planning, a visiting nurse, and a visiting homemaker. These components are necessary to form the basis of a comprehensive "reasonable efforts" protocol to help families with morbidly obese children overcome all the challenges associated with helping their children lose weight.

Family Counseling

The family counseling component ensures all family members are mentally healthy. Severe obesity can often be the result of mental illness or family dysfunction. A family counselor can treat minor mental health problems, especially those that can be solved by talk therapy, such as situational depression.

For more serious mental illnesses, such as chronic depression, the counselor can refer the parent or child to a higher certified mental health professional. Family counseling can also help a family develop and maintain strong bonds and enhance trust so that members are well equipped to provide one another with the emotional support they will need to get through the difficult ordeal of helping a morbidly obese child lose weight.

Health Education

The education component provides parents and children with information about proper nutrition and exercise. Many parents of severely obese children do not act intentionally to inflict harm on their children. Rather, they are often unaware of the composition or importance of a proper diet and exercise.

In the Indiana case involving 4-year-old, 111-pound Cory Andis, for example, his parents told child welfare officials and nutritionists the reason they did not provide their child with a proper diet was because "they did not understand the suggested diets [which] were too hard to follow." In addition, when Cory had to later be hospitalized for conditions related to his severe obesity, his parents were seen giving him a fast food meal. And in the New Mexico case involving 3-year-old, 131-pound Anamarie Martinez-Regino, "[h]er parents blamed the weight gain on 'uneven sidewalks,' which prevented Anamarie from exercising at home," according to an article published by Deena Patel in the Family Court Review.

Further evidence that parents of morbidly obese children are often not malicious but rather just unaware of the importance and composition of a healthy diet and exercise is the fact that these parents are often severely obese themselves. In the New York case of In re Brittany T., for example, Brittany's mother weighed more than 430 pounds. In the Pennsylvania case, In re D.K., the court noted that D.K.'s mother weighed about 600 pounds.

It seems obvious that this will be an ongoing issue for some time - and the question of how to handle it isn't going to be an easy one.

Sharon