AMA Journal of Ethics®

Illuminating the art of medicine

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AMA Journal of Ethics®

Illuminating the art of medicine

Virtual Mentor. April 2010, Volume 12, Number 4: 263-267.

Clinical Cases

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Does Pediatric Obesity Indicate Child Neglect?

Comorbidities and caretaker behaviors differentiate the mere presence of childhood obesity from reportable child neglect.

Commentary by Todd Varness, MD, MPH

At 9 years old, Tiffany is morbidly obese (above the 150th weight percentile for her age, with a BMI of 35). Tiffany was referred to a pediatric obesity clinic by her pediatrician. Over the years, her weight problem had become more pronounced, leading to impaired fasting glucose and hyperlipidemia. Her pediatrician felt the significant increase in her weight over the last 3 years warranted an intensive approach to her obesity. As the pediatric obesity clinic physician took Tiffany’s history, it became clear that she lived in an environment in which physical activity was not encouraged and fast food was a staple. Tiffany’s mother bragged that she frequented fried chicken and hamburger franchises so much that the managers and salespeople knew her by name. When questioned about whether or not she planned on making changes in her daughter’s diet, Tiffany’s mother emphatically stated, “I do not plan on making any changes to Tiffany’s diet. She’s my kid, and I call the shots about what she eats. Fast food tastes better than the stuff you’re proposing. I know she’s bigger than many of her classmates, but at least she’s happy. All of you doctors are rich anyway, and you think I can afford all that stuff you’re telling me to feed my child.”

Learning Objective Understand the comorbidities and caretaker behaviors that differentiate the mere presence of childhood obesity from reportable child neglect.

Since the mother has been the primary contributor to this patient’s learned behavior (poor dietary choices and sedentary lifestyle), can this be seen as medical maltreatment? Should the physician ask for a child neglect ruling and advise authorities to speak with child protective services for Tiffany?

Commentary

With the rapid increase in the incidence of childhood obesity and obesity-related comorbid conditions, this type of case is becoming more common. When families cannot or will not follow through with steps needed to decrease the impact of their child’s obesity, the question of whether such noncompliance constitutes reportable child neglect arises.

Child Neglect

“Child neglect” is typically defined as failure of caregivers to seek or provide necessary medical care, thus placing the child at risk of serious harm. An argument for classifying childhood obesity as neglect could apply when the caretaker of an affected child fails to seek medical care, fails to provide recommended effective medical care, or fails to control their child’s behavior to a degree that places the child at risk of serious harm, including death. When possible medical neglect is reported, child protective services typically investigates the allegations, conducts a comprehensive family assessment of safety and risk, determines the family’s need for additional social and financial services, and if necessary, recommends additional interventions (“check-ins” to determine compliance with recommendations, home visits, removal of child from the home, etc.) to protect the child from harm. Among the many available interventions, removing the child from the home is the most severe. The threshold for doing so in cases of medical neglect is usually high, due to the need to balance the goal of protecting a child from medical harm with the risk of causing serious psychological harm by removing the child from the home.

In general, physicians should report medical neglect only when all three of the following conditions are present:

  1. A high likelihood of serious and imminent harm;
  2. A reasonable likelihood that an available intervention will result in effective treatment;
  3. The absence of alternative options for addressing the problem.

These three criteria can serve as a framework for determining when a particular case might approach the threshold for reporting medical neglect [1].

Is there a high likelihood of serious and imminent harm for Tiffany? The mere presence of childhood obesity, even severe, does not by itself predict serious and imminent harm. Rather, it is the presence of serious comorbid conditions (at any level of obesity) that is relevant when assessing the criteria of “serious and imminent harm.”

What might constitute a serious obesity-related comorbid condition? Childhood obesity is associated with a spectrum of risk [1]. In the vast majority of cases, the child’s excess weight is not associated with a serious comorbid condition during childhood. And, while childhood obesity increases risk for development of multiple diseases as an adult, this does not constitute “serious and imminent harm.” In some cases, however, childhood-obesity-induced morbidities can create a high risk of serious and imminent harm, which could be reversed or improved with weight loss. These conditions include severe obstructive sleep apnea with cardiorespiratory compromise, uncontrolled type 2 diabetes, and advanced fatty liver disease with cirrhosis [2-4].

Tiffany has hyperlipidemia and impaired fasting glucose—do these constitute “serious and imminent” harm? Both conditions are associated with increased risk for adult disease (i.e., type 2 diabetes and cardiovascular disease), but, because outcomes vary widely for individuals with these risk factors, and the feared outcome is in the distant future, the clinical picture at present would not constitute a high likelihood of serious and imminent harm.

Are there effective interventions for Tiffany’s obesity? Is it reasonable to demand that families be able to achieve effective weight loss for their children? And, if it has been impossible for the biological family to reduce a child’s weight, what evidence is there to suggest that a foster family would be more successful?

Lifestyle interventions (diet and exercise) are the cornerstones of treatment for obesity and related complications. Lifestyle interventions are safe and simple in concept, and a sustained negative caloric balance (expending more energy than is consumed) will result in meaningful weight loss. While lifestyle interventions are frequently judged to be ineffective, a recent systematic review from the U.S. Preventive Services Task Force found support for the effectiveness of medium-to-high-intensity behavioral interventions for children and adolescents who were obese [5]. Such interventions typically promote weight loss through diet and exercise modification, but also employ family-based interventions and cognitive management techniques. For Tiffany and other children with obesity-related comorbid conditions, the goal is not resolution of obesity but rather whatever (perhaps modest) weight loss is needed to alleviate the comorbid conditions. In cases of severe obesity with comorbid conditions, the goal need not be a child who is normal weight, but a child who is less obese.

In summary, effective interventions for weight reduction are available for Tiffany, and it is not unreasonable to expect that weight loss occur in either the child’s current setting or with a specifically trained foster family (if removal from the home was pursued). While Tiffany’s current environment may not be the ideal setting for effective weight loss, the family does have access to the pediatric obesity clinic, where behavioral interventions of medium-to-high intensity would certainly be available.

Are there less-drastic alternatives to address this problem than charging medical neglect? In most cases of obesity, families make a good-faith effort to address the problem when made aware of the condition and the potential adverse health consequences. The development of a serious comorbidity can serve as a wake-up call for families, prompting full cooperation with intensified medical services. Whenever obesity is detected during childhood, physicians should recommend available nutrition, exercise, and behavioral interventions, as well as referrals to professionals with appropriate expertise, to ensure that reporting the situation as medical neglect is an option of last resort. It is important to understand that a report of suspected neglect need not lead to the child’s removal from the home; social service agencies and child protective services have less invasive alternatives. Additionally, raising the possibility of removal from the home may affect Tiffany’s mother’s thinking and behavior sufficiently to bring about compliance with the needed changes.

Suggested Course of Action

Tiffany does not appear to be at high risk for serious and imminent harm related to her obesity at this time, although, if she continues on this course, risk for serious harm will increase. Effective treatment is available for Tiffany’s obesity-related conditions and is not being implemented. Alternatives to reporting medical maltreatment, however, have not been exhausted. Therefore, based on analysis of the criteria discussed above, I would discourage the physician from reporting medical neglect at the present time. While Tiffany’s health has been neglected, the consequences of the neglect have not yet reached the threshold for reporting and a request for coercive state intervention.

However, the doctor still has an obligation to vigorously attempt to address Tiffany’s obesity, and to do so now, before the case progresses to one that might indeed meet the criteria for reporting medical maltreatment. Tiffany’s mother’s resistance, although daunting, highlights the need for immediate intervention before the comorbid conditions result in serious harm. While her response to suggested interventions reflects misunderstanding or denial of the risks of obesity, it also exposes social realities and obstacles that will need to be confronted over time. The first step is to establish a trusting relationship with the mother, therefore I recommend refraining from excessive preaching or information overload at the first visit. Rather, I would obtain more information on the child’s environment, reasons why her mother does not perceive or accept the risks inherent in Tiffany’s condition, and possible community resources that might be available as we move forward. With subsequent visits, I would discuss nutrition and physical activity with the initial goal of maintaining Tiffany’s current weight, as opposed to weight loss. I would try to utilize other professional resources (nutrition counseling, health psychologists, etc.) when I felt that Tiffany’s mother was ready for such information.

Finally, and very importantly, I would recommend involving local social services earlier rather than later. Social services should not be reserved only for situations that convincingly meet the criteria for reportable neglect. Social service agencies and child welfare professionals are experts at comprehensive family assessments and identifying a family’s need for services. Their in-home assessment would complement the continued efforts of the medical team, and clarify the seriousness of the physician’s concern about the situation. Recommendations and follow-up regarding healthy food availability in the home and strategies to increase physical activity could keep Tiffany’s health from deteriorating to the point where a charge of medical neglect is unavoidable and may even yield concrete health benefits.

Conclusion

While Tiffany’s case clearly involves neglect, it does not appear to constitute reportable medical neglect. Nonetheless, her case highlights the need for the physician to pursue a number of alternatives before the case progresses to one that would necessitate a report of medical neglect: namely, full efforts at behavioral modification and the involvement of social services. If these efforts fail and Tiffany’s risk progresses to the point of serious and imminent harm, then her physician should report the case as medical neglect.

It is unfortunate that state intervention requires the language of “neglect,” implying some moral judgment about the parent(s). As in many other instances requiring state intervention to protect children, the purpose is not to make moral judgments about parents, or to punish them, but to protect the child from serious harm. Although poverty, lack of affordable healthy food, and even lack of adequate space for exercise may play a role in many cases of severe childhood obesity, the state—and physicians—still have an obligation to protect children if they are at risk of serious and imminent harm.



References

  1. Varness T, Allen DB, Carrel AL, Fost N. Childhood obesity and medical neglect. Pediatrics. 2009;123(1):399-406.
  2. Speiser PW, Rudolf MC, Anhalt H, et al. Childhood obesity. J Clin Endocrinol Metab. 2005;90(3):1871-1887.
  3. Dietz WH, Robinson TN. Clinical practice. Overweight children and adolescents. N Engl J Med. 2005;352(20):2100-2109.
  4. Freedman DS, Mei Z, Srinivasan SR, et al. Cardiovascular risk factors and excess adiposity among overweight children and adolescents: the Bogalusa Heart Study. J Pediatr. 2007;150(1):12-17.
  5. Whitlock EP, O'Connor EA, Williams SB, et al. Effectiveness of weight management interventions in children: a targeted systematic review for the USPSTF. Pediatrics. 2010;125(2):e396-e418.

Todd Varness, MD, MPH, is assistant professor of pediatrics in the Division of Pediatric Endocrinology and Diabetes at the University of Wisconsin School of Medicine and Public Health in Madison. In addition to his clinical practice, he conducts research in ethical issues in pediatric endocrinology and the ethical and policy aspects of newborn screening.

Acknowledgment

The author wishes to thank Dr. David Allen and Dr. Norman Fost for their insightful comments on this manuscript.

Law and Medicine: Pediatric Faith Healing, October 2009

Weight-Related Denial of Insurance for an Infant, April 2010

The people and events in this case are fictional. Resemblance to real events or to names of people, living or dead, is entirely coincidental. The viewpoints expressed on this site are those of the authors and do not necessarily reflect the views and policies of the AMA.