Is Obesity Ever Reportable Child Neglect?
- Identify the key factors which should lead to consideration of reporting children with obesity
- State three objections to reporting cases involving obesity, and the responses to those objections
- State the goal of reporting and possible state action
Isabel (name changed) is a 16-year-old girl admitted to the PICU with nearly fatal respiratory failure, requiring mechanical ventilation, due to extreme obesity. She weighs 440 pounds (BMI 73). Upon further history and evaluation, she is not found to have an identifiable cause for her severe obesity other than excess caloric intake with insufficient caloric expenditure. Her single mother is also extremely obese and has missed several appointments made for Isabel with dietitians.
- Should this case be referred to social services for evaluation for possible neglect?
- What would you want social services to do to protect Isabel from serious harm?
- Is this different in any important way from other forms of medical neglect; e.g., severe failure to thrive due to failure to provide adequate nutrition?
- What should the criteria be for reporting childhood obesity as neglect? In this article we will review the arguments for considering some case of childhood obesity as reportable neglect.
General Criteria for Reporting Medical Neglect
For most of recorded history, abuse and neglect of children was widely tolerated and considered beyond the reach of governmental action. That changed about 150 years ago, and there is now virtual unanimity that governments have an obligation to protect children from serious harm from their caregivers, and all states have statutes requiring health professionals and others to report cases of suspected abuse or neglect.
Medical neglect is typically defined as failure to provide medically necessary treatment for reasons other than poverty or ignorance in circumstances that put the child as risk of serious irreversible harm. Nutritional neglect, resulting in failure to thrive, is one of the more common forms of reported medical neglect.
The criteria for state intervention in alleged abuse and neglect cases typically are as follows:
- A high likelihood of serious imminent harm
- A reasonable likelihood for benefit
- Failure of other alternatives, making state action a last resort
Typical examples of medical neglect include the following:
- Failure to seek medical care when a child is obviously ill.
Example: The highly publicized case of 11-year-old Kara Neumann of Wausau, WI. Kara died at home of type 1 diabetes mellitus after a prolonged illness in which she complained of thirst, could not walk or talk, and became progressively obtunded. Neighbors and relatives urged her parents to seek medical care, but they chose to rely on prayer and were subsequently prosecuted for negligent homicide.
- Failure to consent to medical care.
Example: A 9-year-old girl with scoliosis whose hemoglobin dropped progressively following corrective spine surgery. Her parents, who were Jehovah’s Witnesses, refused to agree to a blood transfusion and she died of shock.
- Failure to comply with recommended medical care.
Example: A 13-year-old boy with new-onset Hodgkins Disease, with an estimated 90% chance for cure with standard treatment. His parents missed several oncologic treatment appointments. A court ordered guardianship and standard treatment, but his parents took him to Mexico for alternative therapy where he died.
These cases all included religious and cultural preferences of the parents, but the reasons for neglect are not considered relevant in deciding whether the state should intervene. The US Supreme Court has ruled that first amendment rights to practice one’s religion do not extend to practices that expose children to a risk of serious harm. Isabel’s case seems most like the third example, although the failure to comply with recommended care did not seem related to religious or cultural preferences. In summary, a child such as Isabel meets the traditional criteria for reporting suspected neglect and possible state action. She was at high risk of imminent death or serious irreversible harm, both before and after her admission to the PICU, and her mother seemed either incapable or unwilling to take corrective actions that could reduce Isabel’s risk of dying.
Objections and Responses to Considering this Case as Neglect
Critics of proposals to require reporting of cases like Isabel’s point to several concerns:
- “Obesity is multifactorial, and environmental change only addresses one variable.”
This is certainly true, and placing the child in a different home is unlikely to “cure” the obesity. This child is highly likely to be obese however long she lives, but the goal of intervention is not to cure the obesity, but to bring about enough weight loss to reduce the risk of premature death or serious irreversible harm. The goal is to make Isabel less obese, not non-obese. If she could lose 100 pounds, she would still be morbidly obese, with a BMI above the 99th percentile (see Figure), but her risk of dying from respiratory failure would be markedly diminished.
Figure: The goal of intervention is to reduce the child’s weight from A to B, not necessarily to achieve a weight in the normal range.
- “There is no evidence that changing the home will lead to significant sustained weight loss.”
Sparse data on state intervention involving patients like this exist, because in the past reporting has been extremely rare. Ludwig reported a patient who lost 100 pounds in foster care and said she was “never happier.” Sometimes the threat of state action – “a shot across the bow” - may lead parents to take more effective action. One of our institution’s patients similar to “Isabel” lost 100 pounds following discharge after a serious discussion with her parents about the possibility of a report. Moreover, the absence of proof cannot be a deterrent to interventions with a reasonable prospect of benefit. The majority of treatments in pediatrics have never been rigorously tested for safety and efficacy in relevant age groups. There is certainly a need for research on outcomes following state action. While prospective randomized trials are not feasible, a national registry of cases of extreme obesity could provide valuable information for future practitioners and policy makers.
- “Removal of a child from the home can cause psychological harm.”
This claim applies to all cases of serious child abuse and neglect where short- or long-term placement outside of the home is often necessary to protect the child from serious irreversible harm. Possible harms from treatment must be weighed against the likely harms of not intervening. Cases in which placement are contemplated involve a substantial risk of premature death. In such cases, it would be irrational to avoid intervention to protect a child from psychological harm Unlike cases of physical child abuse, separation of the child from her familiar parent(s) need not be a major component of placement in another home. The ideal home would be close by, preferably with a relative who is familiar to the child, with daily contact with the rearing parents. The critical component of placement is to provide an environment where weight loss is more likely to occur, usually due to caloric restriction.
- “This is a slippery slope which will result in millions of children being removed from their homes.” All interventions can be misused, but the possibility of misuse cannot be a justification for prohibition of treatments that can be safe and effective. The guidelines we have proposed would apply to a minuscule proportion of this country’s obese children. A key point is that state intervention should be considered only for those children with medical complications – e.g., respiratory failure, impending liver failure, or uncontrolled diabetes – attributed to extreme morbid obesity. These children are at risk of imminent death, while still in childhood, before they can become autonomous adults and decide for themselves if they want to take responsibility for their own lives. Thus, drastic intervention is not justified in the vast majority of children who are simply obese, or severely obese, or even morbidly obese. The number of children who meet these criteria within the UW-Health system, which follows a substantial population of obese children, has been less than five per year. We don’t know how many such children exist nationwide, but the order of magnitude would be far short of “millions.”
- “It’s wrong to blame parents who have tried to control their child’s weight.”
The purpose of child abuse and medical neglect reporting is not to blame or punish parents, but to protect children from serious, irreversible harm. The child abuse reporting law is not part of the criminal statutes, but in a separate “children’s code,” which states explicitly that the purpose is protection, not punishment. While some cases of child abuse involve criminal behavior and prosecution, the overwhelming majority, and particularly cases of childhood obesity, do not. The statutory language, which gives the state the authority to intervene and requires reporting of suspected cases, is unfortunate in that it uses the language of abuse and neglect, terms which are unduly stigmatizing. Parental stigmatization could be reduced if the relevant statutes were called “children in need of protection, or CHIP laws,” rather than the inflammatory and judgmental language of “abuse and neglect.”
Another argument that parents should not be held responsible for their child’s obesity refers to the genetic contributions to obesity. It is increasingly clear, as is the case with virtually all diseases, that genetic variation accounts for a substantial part of the risk for both becoming obese as a child, as well as developing serious obesity-related complications, such as type-2 diabetes. But regardless of the genetic contribution, weight gain is determined by modifiable energy balance – calories in and calories expended – and virtually any obese child will experience better weight control if diet and exercise can be modified. The fact that a child is genetically predisposed to obesity does not alter the parent’s or the state’s responsibility to protect the child from premature death or other irreversible harm.
- “The proposed criteria are too strict, and the state should intervene sooner, before the child develops life-threatening complications.”
Further experience and debate may lead to a shift in this direction, but at the moment we are at the front end of our experience with state intervention for any form of childhood obesity. New interventions typically start with the worst cases, since children at risk of imminent death have the least to lose from possibly risky interventions. If intervention in these cases can be shown to effective, expansion of the criteria could be considered. This could perhaps include children who are on a course to develop life-threatening complications of morbid obesity, such as fatty infiltration of the liver, that may not kill them in childhood but will lead to irreversible changes that the child will not be able to alter when he or she becomes an adult.
- “Removal from the home should be a last resort.”
We agree that this is an important requirement of the criteria we have proposed. It is a general principle in medicine, and public policy, that the least harmful or least restrictive approach should be tried if time permits. The initial approach should always be to change the child’s (and family’s) lifestyle regarding diet and exercise, in selected cases followed by (a very limited armamentarium) of drug therapies. Neither of these approaches has been consistently ineffective in producing sustained weight loss in this population. Bariatric surgery in adolescents is a more recent approach, and while it is too soon to know its long-term benefits and risks, could become a useful approach. Experimental approaches, such as gene therapy, are being investigated.
In conclusion, a very small part of the expanding epidemic of childhood obesity involves children who are at high risk of serious imminent harm and unable to protect themselves. When this occurs, hospitalization or placement in group homes or with specifically trained foster care families could reasonably be expected to achieve modest weight loss sufficient to alleviate co-morbid conditions. The goal need not be a normal-weight child, but a less obese child. There has been a long-standing consensus that state intervention is warranted when children are at risk of serious irreversible harm which their parents are unable or unwilling to prevent.
Allowing a child to lose the opportunity to live into healthy adulthood due to obesity-induced disease and when effective treatment is available, runs contrary to the central pediatric care mission of preserving a child’s opportunity for an open future.
Much of our thinking about this topic was shaped by our late colleague, Dr. Todd Varness.
- Varness T, Allen DB, Carrel AL, Fost N. Childhood obesity and medical neglect. Pediatrics. 2009;123(1):399-406
- Schoetz, David (2008-03-27). "Parents' Faith Fails to Save Diabetic Girl." ABC News. Archived from the original on 2009-02-28. Retrieved 2009-02-28.
- Murtagh L, Ludwig DS. State intervention in life-threatening childhood obesity. JAMA 2011;306(2):206-7.
- Allen DB, Fost N. Obesity and neglect: it's about the child. J Pediatr. 2012 Jun;160(6):898-9. Epub 2012 Apr 14.