Child Protective Services and Obese Children

The past week saw a signficant increase in the number of search engine hits for obese children and intervention, but it wasn't to report some new medial breakthrough in their care. Rather, this attention was spurred by a recent Journal of the American Medical Association (JAMA) article, recommending the removal of a small number of morbidly obese children from their parents when they are believed to be in imminent danger. There are a number of serious discussion growing out of this particular article, but it is also accompanied by a considerable amount of name calling come from various directions in the comment sections. In contrast, I hope to provide my readers with some questions to challenge the articles in a logical and much needed manner.

Overall, as the article itself (and another article from Pediatrics in 2009), emphasizes, childhood obesity is a serious problem that is affecting more and more children across our nation. No one can seriously argue that we are not facing an epidemic. These morbidly obese children are facing diabetes, sleep apnea, hypertension not only in their future adulthood, but sometimes beginning in their childhood. With such staggering numbers growing and with such serious consequences, most agree that something must be done. The problem begins here, with the simple question "What do we do?"

Therefore, a goal of the proposed intervention should be stated. Do we aim for a perfect weight? Do we aim for a threshold of weight loss? Do we just try to avoid the comorbidities listed above? Before implementing any solution, we need a reasonable target. The article from Pediatrics provides a somewhat clearer picture of its purpose in contrast to the JAMA article which discussed the importance of avoiding complications but did not put this into a simple purpose statement. The Pediatrics article proposes a target of avoiding the complications of morbid obese which present an immediate threat to the child's health. This seems reasonable at face value prior to a closer scrutiny.

The closer scrutiny asks two questions: First, "Is the intervention effective at reaching this goal?" In the case of removing a child from their families in order to treat their obesity, case studies are presented, but no study is presented as anything near conclusive evidence. Basically, the authors are saying that they once knew a patient with this condition that benefitted from this intervention. It worked for them, so it should work for everyone else just as well. To their credit, the authors of the Pediatrics article try to address successful strategies such as lifestyle interventions, medical therapies, and surgical therapies. However, neither article provides any study level evidence that removing children from their parents is either effective for the stated problem, or is effective without producing harmful effects in other important areas of a child's life. They seem to be advocating for something rather untested, basing their claims mainly on anecdotal evidence. That concerns me greatly.

The second question is "Is that target worth the cost of the intervention or solution?" This addresses something alluded to above: what side effects may occur from this intervention. If I prescribe a pill for a patient, they are reasonable to ask what are the side effects. If they advocate removing children from their parents, it is reasonable, if not a requirement to ask "What ill effects may be predicted by this intervention?" Obviously, there are a number of potential harms from this intervention. Removing children from the parents to whom they are dearly attached and placing them in foster homes may not result in long term benefits overall even if weight is lost. Our foster system is not able to absorb these vulnerable children nor care for the stigma such a placement will entail.

I hope to revisit this issue soon, but so far I am not convinced by the arguments or proofs found in these articles. I have not heard convincing reasons to overturn the fundamental rights of parents to direct the upbringing of their own children.