Should Child Obesity be an Issue for Child Protective Services? A Call for More Research on this Critical Public Health Issue

Childhood Maltreatment: Does Extreme Childhood Obesity Fit the Definition?

Child maltreatment is defined differently from state to state, as well as between practice and research, and even varies across studies within the empirical literature. That said, in order to provide common organizing terminology for this review, we utilize the definition provided by the Centers for Disease Control and Prevention (CDC; Leeb, Paulozzi, Melanson, Simon, & Arias, 2008): “Any act or series of acts of commission or omission by a parent or other caregiver (e.g., clergy, coach, teacher) that results in harm, potential for harm, or threat of harm to a child.” “Acts of commission” are defined as intentional acts that could cause harm to a child, whether or not the caregiver intends harm or the child is actually harmed as a result (Leeb et al., 2008). Acts of commission include physical, emotional, and sexual abuse. In contrast, “acts of omission” are defined by the failure of a caregiver to provide for the educational, physical, or psychological needs of a child or to prevent the child from harm (i.e., inadequate supervision, exposure to a violent environment; Leeb et al., 2008). The broad category of failing to provide for or protect a child is typically referred to as neglect, which can also include medical neglect (i.e., the failure to provide for a child’s medical needs).

Although the prevalence of maltreatment varies depending on whether CPS allegations, substantiations, or other methods (e.g., youth report) are utilized (e.g., CDC, 2010; Finkelhor, Turner, Ormond, & Hamby, 2009; Child Welfare Information Gateway, 2012), estimates, regardless of measurement strategy, are staggering. During the most recent reporting period, for example, approximately 3.3 million referrals for alleged maltreatment of an estimated 5.9 million children were made to CPS agencies; of these, more than half (61%) of the referrals were picked up for investigation or assessment; and one fifth of those referrals that were picked up found at least one child to be a victim of maltreatment (Child Welfare Information Gateway, 2012). The most common form of maltreatment was neglect (78.3%), a pattern seen in prior reporting periods as well, followed by physical abuse (17.6%), sexual abuse (9.2%), and emotional abuse (8.1%; Child Welfare Information Gateway, 2012). Of note, estimates of the prevalence of child maltreatment are typically even higher when unofficial data (e.g., youth report) are utilized (e.g., Everson et al., 2008; Finkelhor et al., 2009; Mennen, Kim, Sang, & Trickett, 2010).

So, does extreme childhood obesity fit within the current conceptualization of child maltreatment That is, if we define child obesity as harm or the potential for harm, can we say that acts of commission or omission on the part of a caregiver whether intended or not cause obesity and/or fail to protect the child from obesity? Those who advocate for CPS involvement in cases of extreme childhood obesity generally contend that obesity stems from (a) a caregiver’s neglect of proper nutritional needs of a child (i.e., similar to the inclusion of undernourishment and/or failure to thrive included in current definitions of neglect) and/or (b) the failure of parents to seek and remain engaged in early intervention and prevention programs targeting their child’s overweight, which some consider equivalent to medical neglect in particular (see Varness et al., 2009, for a review). In turn, some argue that such circumstances may necessitate that health care professionals contact CPS agencies (see Murtagh & Ludwig, 2011, for a review).

Yet, focusing intervention efforts on caregiver acts of commission or omission alone may overlook the complex interrelationship of factors that are theorized to induce obesity and, in turn, must be considered in efforts to prevent and/or treat it (see Ben-Sefer, Ben-Natan, & Ehrenfeld, 2009, for a review). Our review of these multiple and interactive factors is not meant to be original or exhaustive; rather, we briefly summarize and present information reviewed elsewhere. Our aim is simply to provide a foundation for a more focal discussion of the consideration of extreme childhood obesity as an example of child maltreatment and, in turn, necessitating CPS involvement. To this end, some discussions of obesity highlight the broader evolutionary context in which obesity must be considered. For example, some assert that the dramatic increase in the prevalence of obesity may be the result of evolutionary changes in the brain that occurred as a function of early ancestral hunting and gathering periods (see King, 2013, for a review). That is, King (2013) contends that while hyperactivity in brain reward circuitry related to sensory and reward control of food intake may have been adaptive during alternating periods of food availability and deprivation, they may in fact lead to overconsumption in modern day food-rich and nutrient-dense environments (King, 2013; also see Carnell, Gibson, Benson, Ochner, & Geliebter, 2012, for a review).

Building upon an evolutionary context, specific processes that occur during the fetal and early postnatal period, including developing proportions of fat and lean body mass, central nervous system control of appetite, and pancreatic structure and function, may induce lifelong changes in a child’s size, shape, and metabolism (Adair, 2008; Oken & Gillman, 2003; also see Lillycrop & Burdge, 2011, for a review). In turn, both low- (e.g., nutritional constraint during pregnancy) and high- (e.g., maternal obesity, gestational diabetes) birth-weight have been linked to obesity, as well as health correlates linked to obesity, including cardiovascular disease and the metabolic syndrome (i.e., hypertension, insulin resistance, type 2 diabetes, dyslipidaemia, and obesity; Lillycrop & Burdge, 2011). The processes linking high-birth-weight to obesity may be more obvious, but there is also evidence that “catch-up growth” among low-birth-weight children (i.e., greater body fat relative to lean body mass) occurs as a means to reach puberty at a rate similar to that of similar-aged, normal-weight peers (Lillycrop & Burdge, 2011).

Beyond or in conjunction with the evolutionary and prenatal context of obesity, genetics as well as heritable changes in gene expression (i.e., epigenetics) have also been examined (see Bird, 2007; Goldberg, Ellis, & Bernstein, 2007; Jia et al., 2011; Kral & Faith, 2009; Lillycrop & Burdge, 2011, for reviews). For example, some empirical work to date focuses on the deoxyribonucleic acid (DNA) methylation of tissue-specific genes that occurs throughout the prenatal and early postnatal periods. Importantly, environmental disturbances, including maternal over- and undernutrition, have been shown to alter methylation within genes that control processes such as metabolism and appetite–energy balance associated with overweight and obesity later in life (Lillycrop & Burdge, 2011).

Likely considered to interact with the aforementioned evolutionary, prenatal, and genetic factors, environmental correlates of childhood obesity have also been a primary focus of attention. For example, children exposed to more advertising of unhealthy foods are more likely to prefer unhealthy foods more than healthier versions (Boyland et al., 2011; Dorey & McCool, 2009). In addition, the child’s community and school contexts influence health habits. For example, access to physical education classes and healthy breakfast and lunch options in schools as well as the availability of grocery stores, safe playgrounds, and sidewalks in the broader community play a role in child overweight and obesity (Burgeson, Wechsler, Brener, Young, & Spain, 2001; Riis, Grason, Stobino, Ahmed, & Minkowitz, 2012). These factors are in large part determined by the socioeconomic status (SES) of the family and the neighborhood in which the child resides, both correlates of childhood overweight and obesity. That is, lower income families are more likely to experience multiple factors associated with obesity including food insecurity and not only a lack of, but impediments to, healthy eating and exercise options in the home or community (see Shrewsbury & Wardle, 2008, for a review).

Finally, to bring our attention back to the role of caregivers in particular, leaders in the field generally agree that parents and the family context significantly influence child socialization (e.g., Bronfenbrenner, 1986; Cicchetti & Lynch, 1993; Cummings, Davies, & Campbell, 2002), including the norms children adopt regarding weight-related behaviors (e.g., eating and physical activity; see Rosenkranz & Dzewaltowski, 2008, for a review). Caregiver attitudes and behaviors influence a child’s eating attitudes and behaviors through the foods they provide, family mealtime, and modeling of eating habits (e.g., Hanson, Neumark-Sztainer, Eisenberg, Story, & Wall, 2005; Robinson-O’Brien, Neumark-Sztainer, Hannan, Burgess-Champoux, & Haines, 2009; Spurrier, Magarey, Golley, Curnow, & Sawyer, 2008). Similarly, caregivers influence a child’s physical activity level by providing play and sports equipment, modeling activity and fitness, and setting limits on television viewing (e.g., Dunton, Jamner, & Cooper, 2003; Spurrier et al., 2008; Trost, Pate, Ward, Saunders, & Riner, 1999).

In summary, the vulnerability for childhood obesity is likely induced as a result of the interaction of evolution, genetics, and the pre- and postnatal environments, including caregiver behavior; however, it is our understanding that caregiver acts of commission or omission cannot at this point, given the state of the literature, be characterized as the primary cause of or failure to prevent childhood obesity. Susceptibility may be historically rooted in evolutionary processes that continue to unravel across time beginning in utero and continuing in infancy and childhood, with environmental factors in the home, school, community, and media influencing subsequent lifestyle factors that further exacerbate risk. In turn, we are not yet convinced that CPS involvement will be the panacea that we are looking for in our fight against childhood obesity. Accordingly, we now turn to central research questions that need to be addressed if we are to better understand the merits for or against CPS involvement as well as other prevention and intervention approaches.

CPS Involvement in Extreme Child Obesity: Current Research and Future Directions

It is our contention that combating the sense of hopelessness that has evolved among some regarding the efforts to battle childhood obesity depends just as much on systematically evaluating the potential of our available and less extreme options, including both prevention and intervention efforts already in the field, as it does evaluating the potential role of less traditional approaches like CPS involvement.

Is it possible to better coordinate an efficacious, multidisciplinary approach to the prevention of childhood obesity? We do not necessarily disagree with the recommendation to emphasize the role of parents and parenting in the prevention and treatment of childhood obesity. In fact, experts agree that targeting families may be the key to successful prevention of childhood overweight (e.g., Golan, Weizman, Apter, & Fainaru 1998a, 1998b; Golan, Fainaru, & Weizman, 2001). Nevertheless, relatively little work has been done in this area, and prevention with families is admittedly not simple. Prevention efforts must take into account the fact that many caregivers, especially those with low levels of education, do not recognize that their child is overweight or at risk of becoming overweight (e.g., Cottrell et al., 2007; Huang et al., 2007; Miller et al., 2007). Moreover, all families confront daily challenges and stressors that take precedence over something considered a potential future problem (e.g., Paffenbarger, Blair, & Lee, 2001; Zehle, Wen, Orr, & Rissel, 2007). Accordingly, caregiver responsibilities focus first and foremost on the basics of child care, including obtaining, preparing, and serving food, creating safe and productive play time, providing opportunities for naps and sleep, and immediate health care needs. Yet, improving caregiving very early in a child’s life could be a critical first step. For example, although this work is still in its infancy and relies largely on animal models, literature suggests that epigenetic processes, including the aforementioned DNA methylation induced by maternal diet, can be prevented or reversed postnatally. Treatment with leptin between postnatal days 3 to 13 for rats born to dams which experienced a 70% reduction in food intake during pregnancy yielded a normalized food intake, motor activity, body weight, fat mass, and fasting plasma glucose in adult offspring (Vickers et al., 2005; also see Lillycrop & Burdge, 2011). Utilizing this research to inform studies of similar interventions in humans is critically important but would of course need to proceed cautiously.

Research also needs to examine the potential impact of targeting children and families in the highest risk groups, including lower income and minority families, with available prevention programs. For example, both Child-Parent Centers (e.g., Reynolds & Robertson, 2003) and Nurse-Family Partnership (e.g., MacMillan et al., 2009) provide comprehensive educational and family support to economically disadvantaged children and their parents. The nurse–family partnership targets better pregnancy outcomes, improved child health and development, and increased economic self-sufficiency among low-income families with the aim of preventing child abuse, reducing juvenile crime, and increasing school readiness. Could such a program be used more explicitly toward the aim of preventing child obesity? Would mothers enrolled in such programs have healthier weight infants who are less vulnerable to obesity over the life course than infants of mothers not enrolled? Of course, this question relies on research designs with long-term follow-up, a time-intensive and, in turn, expensive venture. However, conducting cost-effectiveness analyses could determine whether such programming results in significant cost savings relative to the current and projected economic impact of obesity and/or the costs of DSS involvement (Ministry of Health, 2008; Wang et al., 2008; WHO, 2005).

Similarly, surprisingly little prevention research has been conducted with parents of young children (see Gerards, Sleddens, Dagnelie, de Vries, & Kremers, 2011, for a review). Pediatricians are on the frontlines of the battle against obesity, as caregivers look to them for recognition and knowledge about the health issues affecting their children. Although data from multiple projects demonstrate that overweight tends to track throughout the lifespan (Freedman et al., 2005; McCormick, Sarpong, Jordan, Ray, & Jain, 2010; Nader et al., 2006), medical records reveal that clinicians rarely address the issue of child overweight with parents (McCormick, et al., 2010). This relatively untapped prevention opportunity must proceed, however, with a broader understanding of the stigma that many parents feel related to their child’s overweight (Edmunds, 2004; also see Schwartz & Puhl, 2003, for a review). In Edmunds’ (2004) work, for example, parents report responses from health care professionals regarding their child’s overweight ranging from helpful to negative and dismissive. These data, in turn, suggest untapped research opportunities to examine how to improve physician involvement in the monitoring of children’s overweight at well child visits and parental education on healthy childhood diet and activity as well as the potential impact of such preventive efforts (Puhl, Peterson, & Luedicke, 2013).

Moving from models focusing on the physical to the mental or psychosocial health of the child as well, some researchers have modified existing parenting programs to incorporate messages around healthy weight and healthy weight-related behaviors with promising results (see Gerards et al., 2011, for a review). Other programs like the Parenting Strategies for Success (SOS) Program (Ward et al., 2011) are developed from the bottom-up utilizing theory and behavior change principles from both the established parenting interventions and the obesity prevention literature. This work is still in its relative infancy, however, and we certainly do not know the long-term impact of such approaches. For example, if epigenetics is truly at the core of the induction and progression of childhood obesity, does such parenting prevention programs with young children afford an adequate dosage of information and skill building to move a child from a trajectory toward protracted obesity to a trajectory toward maintenance of healthy weight and lifestyle? Or, will vulnerable children require lifelong information, support, and intervention to maintain a healthy weight once the cascade of processes begin in utero? These are important research questions that need to be addressed, in order to make progress against the growing obesity epidemic.

Can we better facilitate the dissemination of and engagement in evidence-based treatment programs for childhood obesity? Child obesity intervention programs that include caregivers as the explicit agents of change appear to be the most efficacious intervention approaches, particularly those that target general parenting behavior as well as parenting behaviors specific to diet and activity (see Kitzmann & Beech, 2006, 2011, for reviews). If such programs exist, then how do we maximize their availability and use beyond the ivory tower and in real-world practice settings (Graeff-Martins et al., 2008)? The disconnect between research and practice in the case of interventions designed to improve the health and well-being of children has been discussed extensively in the broader literature and the field of obesity appears to be no exception (see Belfer & Saxena, 2006; Kazak et al., 2010, for discussions about increasing the reach of evidence-based interventions in the area of child mental health).

In part, this disappointing state of affairs can be attributed to a lack of connection between university clinic and research settings in which interventions are developed, including family-focused treatments for obesity and community-based health care settings where families seek treatment for their children (National Advisory Mental Health Council Workgroup on Child and Adolescent Mental Health Intervention Development and Deployment, 2001). Although practitioner awareness of family-focused obesity intervention programs is certainly a factor in successful dissemination and implementation, increasing the availability of and access to treatment programs is not enough (Chadwick Center on Children and Families, 2004; Funderburk, Ware, Altshuler, & Chaffin, 2008). Certainly, traditional training mechanisms (e.g., continuing education lectures, readings, training workshops) may facilitate dissemination of family-focused obesity treatment programs beyond research clinics to physicians, nurses, social workers, and case workers working with obese children. As highlighted in related fields, however, ongoing opportunities for reviewing, practicing, and receiving supervision in the implementation of the evidence-based treatment approach are even more critical for efficacious implementation in real-world practice settings (e.g., Funderburk et al., 2008; Kelly et al., 2000; Van den Hombergh, Grol, Van den Hoogen, & Van den Bosch, 1999). Accordingly, a myriad of research questions remain to be answered, and the answers have the potential to dramatically impact the effectiveness of obesity intervention efforts. How do we increase awareness and acceptability of evidence-based obesity intervention programs among physicians, nurses, social workers, and case managers? How do the developers of evidence-based obesity treatment programs ensure that they are being utilized in a way that is consistent with the core theory and components of the programs? How do we teach providers to tailor manualized, evidence-based obesity treatment programs to the broader presenting issues and needs of the family without compromising the efficacy of the program?

Of course, in addition to better understanding how to best disseminate evidence-based obesity treatment programs, we also need more research on what predicts child and family engagement and retention in such programming (see Gopalan et al., 2010; Ingoldsby, 2010; McKay & Bannon, 2004, for reviews on family engagement in health services more generally). For example, Ingoldsby (2010) examined family-focused interventions for children’s mental health issues and reported that many families receive less than half of the planned psychosocial interventions. Lack of caregiver acceptability of the intervention approach is likely one reason for engagement and retention issues with caregivers in obesity prevention and intervention programs (e.g., “My child is not overweight!” or “My child is the one who is overweight, why do you want to meet with me?”). However, work in the area of mental health also shows that parents still may not engage in and complete treatment even when they understand the rationale behind the programming and believe it to be an acceptable approach to treatment (Mah & Johnson, 2008).

At least in part, problems with caregiver engagement and retention are understandable, given the relatively high-demand nature of family-focused obesity interventions (e.g., Kitscha, Brunet, Farmer, & Mager, 2009; Sonneville, LaPelle, Taveras, Gillman, & Prosser, 2009). The majority of programs, like many other treatments for childhood disorders, occur within a clinic setting. Although there are practical and economical reasons for this, a clinic-based approach requires caregiver transportation, as well as session and travel time, typically on a weekly basis for several months. For many caregivers, the time commitment and cost of such an approach may be overwhelming, if not prohibitive. Yet, newer approaches, like that of Kids and Adults Now!–Defeat Obesity (KAN-DO; Ostbye et al., 2011), represent a more family-friendly approach to obesity prevention in young children. KAN-DO consists of eight mailed monthly kits as well as motivational counseling calls and a single group session. Mothers are targeted during what is considered a “teachable moment” for health behavior change (the birth of a new baby), and intervention content addresses the following: parenting skills (e.g., emotional regulation, authoritative parenting); healthy eating; and physical activity. The long-term impact of such family-friendly approaches has the potential to tell us a great deal about increasing the reach of available evidence-based obesity interventions for children and their families.

Is obesity a sign or symptom of maltreatment that would lead to CPS involvement for more traditional forms of maltreatment? There is data to suggest that obesity is correlated with child maltreatment, although the specific nature of the association has yet to be fully disentangled. Some studies examine maltreatment and obesity cross-sectionally or in short-term prospective designs in childhood, others examine maltreatment retrospectively in obese adults, and still others follow maltreated youth over time into adolescence and adulthood (see Noll & Shenk, 2010, for an introduction to a special section on child maltreatment and health outcomes). For example, in a sample of preschool children (n = 2,412) in the Fragile Families and Child Wellbeing Study, a birth cohort study of children born between 1998 and 2000 in 20 U.S. cities, neglect, but not physical or psychological abuse, at age 2 was associated with an increased risk of obesity 1 year later after controlling for demographics (the study did not include childhood sexual abuse [CSA]). Yet, in a prospective cohort design Bentley and Widom (2009) showed that court-substantiated childhood physical abuse from ages 0 to 11 years, but not sexual abuse or neglect, predicted significantly higher body mass index scores in adulthood 30 years later in a sample of 713 men and women (mean age = 41), after controlling for other established risk factors for obesity. Still another prospective study by Noll, Zeller, Trickett, and Putnam (2007) followed 84 females with substantiated cases of childhood sexual abuse (CSA) and 89 demographically matched, but non-abused, girls from childhood (age 6) to adulthood (age 27). Although females with CSA histories were not more likely to be obese in childhood or adolescence, the women with CSA histories were significantly more likely to be obese in adulthood (42.25%) than women without CSA histories (28.40%). Such apparent inconsistencies in the literature make it difficult to disentangle the link between maltreatment and obesity; however, it is likely the case that maltreatment is associated with obesity for some youth, but not all, and certain factors (e.g., severity of abuse) may increase the strength of the association (Gustafson & Sarwar, 2004; Stevelos & White, 2010).

Explanations of the link between maltreatment and obesity are varied and include (a) binge eating as a strategy to compensate for the emotional trauma of maltreatment; (b) a possible “adaptive function” of obesity as a self-protective mechanism against further attention, especially in cases of CSA; and (c) psychophysiological alterations that occur in response to the trauma of maltreatment that are associated with obesity (e.g., dysregulation of the hypothalamic–pituitary axis functioning and resulting increase in peripheral cortisol; e.g., Bentley & Widom, 2004; Gustafson & Sarwar, 2004; Stevelos & White, 2010). Rather than maltreatment causing obesity, it may also be the case that maltreatment and obesity are correlated because both are correlated with other third variables such as similar health outcomes. That is, child maltreatment is linked to a number of health conditions that are also correlated with obesity, including diabetes, cardiovascular disease, and respiratory ailments (see Noll & Shenk, 2010, for a review).

Determining whether maltreatment is a cause or correlate of obesity and related health conditions is an important research direction. This research would likely rely on longitudinal research that assesses multiple types of maltreatment, obesity, and the mechanisms posited to link maltreatment and obesity, with analytic strategies that provide an opportunity to disentangle the unique contributions of each. For example, the link between child maltreatment and various health conditions is maintained even after controlling for BMI (Widom, Czaja, Bentley, & Johnson, 2012), suggesting that maltreatment contributes over and above overweight or obesity. At an even more practical level, however, research should aim to better understand childhood obesity (or its associated health conditions also known to be associated with maltreatment) as a potential sign or symptom of maltreatment. That is, even if the specific direction of associations or pathways are not clear, a solid foundation of research suggests that maltreatment, obesity, and other health conditions are associated. In turn, would characterizing child obesity or its broader health correlates as a potential sign of child abuse or neglect, similar to a bruise, broken bone, or failure to thrive, increase the likelihood that health care providers will consider the child’s obesity within the broader child and family context? Would such an approach increase the likelihood that providers would facilitate appropriate intervention options and support for such intervention options whether maltreatment is occurring (which would merit CPS involvement) or not (Lanier, Johnson-Reid, Stahlschmidit, Drake, & Constantino, 2010)?

Is CPS involvement in cases of extreme child obesity an efficacious intervention option? The two suggested options for CPS intervention are lower level CPS involvement in facilitating family lifestyle changes and removal of the extremely obese child from the home. Yet, surprisingly little empirical attention has examined the efficacy of either of these options. Starting at the most basic level, an initial research question must be the extent to which there is “buy-in” for such an approach from those on the front lines or the caseworkers themselves. As highlighted in the Robert Wood Johnson collaborative series with Frontline, “Failure to Protect”, the child welfare system in the United States is not without controversy. Perhaps most central to the debate is the issue of whether caseworkers have adequate time and resources to effectively manage current, let alone increased, caseloads (Goodman, 2003). For example, findings from the Child Welfare Workforce Survey (Cyphers, 2001, p. 5) suggest that the problems plaguing child welfare are “complex, multi-dimensional, and widespread,” including demanding caseloads, insufficient resources for families, low salaries, workers not feeling valued, and too much time in administrative activities such as travel, paperwork, and courts. Moreover, the cost of maltreatment as currently defined (i.e., neglect, physical, sexual, and emotional abuse) is substantial. A recent study, for example, found that the total lifetime estimated costs associated with just 1 year of confirmed maltreatment cases are approximately US$124 billion dollars (Fang, Brown, Florence, & Murphy, 2012).

Given this information, the next critical question is how we train and mobilize an already overtaxed CPS system to stretch its reach and roles even further to now be at the frontlines of the fight against the obesity epidemic as well. At a minimum, this new role would likely need to include more education in not only nutrition, physical activity, and strategies of health behavior change but also training in theory and intervention targeting the link between parenting behavior, other contextual influences (e.g., neighborhood, school, etc.), and child health behaviors. What is the most effective process for rolling out such changes? Are there certain caseworkers or CPS agencies better suited to handle these additional responsibilities and why? How long would the process of gaining buy-in and training caseworkers to adequately facilitate family-focused changes toward improved health behaviors take? What impact would such an approach have on a family in which obesity is heritable and for a process that was initiated to target obese children in utero?

Beyond training CPS workers to facilitate family-focused changes to better manage an extremely obese child’s weight or facilitate weight loss, some have recommended CPS removal of the child from the home, particularly in cases of extreme obesity. To put such a recommendation in context, the Adoption Assistance and Child Welfare Act of 1980 (Public Law 96-272) and the Adoption and Safe Families Act of 1997 (ASFA) specify that every effort should be made to keep children in their homes; however, removal is sometimes deemed necessary. In cases of removal, legislation suggests that youth be placed in the “least restrictive environment,” typically defined as placement with an extended family member if possible (Beeman, Kim, & Bullerdick, 2000). Foster placements have increased dramatically in recent years, and current statistics estimate that over 500,000 children in the United States are in foster placement at any given time (American Academy of Child and Adolescent Psychiatry, 2005). Reunification of children and parents is the goal in cases of removal, and two of the three youth in foster care are reunited with their parents within 2 years (American Academy of Child and Adolescent Psychiatry, 2005). In cases of reunification, child welfare agencies typically work with parents to overcome or at least remediate the issues that led to the child’s removal from the home; however, some controversy exists regarding whether reunification leads to the most optimal outcomes for all youth (e.g., Gelles, 1993; Litrownik, Newton, Mitchell, & Richardson, 2003; Wells & Guo, 1999). Adoption or long-term foster placements are options for youth when parental rights are terminated. So, does removal and potential reunification process make sense for obesity?

As highlighted by Yanovski, Yanovski, and Horlick (2011), removal of a child from the home is typically only mandated in cases of imminent danger, when the benefits of such an extreme approach outweigh the potential harm. However, the dangers for an obese child are rarely “imminent.” Obesity is more typically associated with a chronic and prolonged trajectory of worsening health over time, including the development of secondary health conditions (e.g., asthma, type 2 diabetes). Yet, these secondary health conditions are also typically not associated with imminent danger, unless neglected or poorly managed. If these secondary health conditions were neglected or poorly managed, however, it would already meet the criteria for medical neglect, whether or not a child is obese. Accordingly, an important question that could likely be answered from available CPS records nationwide is the percentage of youth who are removed from their homes due to medical neglect of health conditions linked to obesity. What are the conditions under which most of these youth are removed, and what was the precipitating event that led to the removal (i.e., what led to a family meeting criteria for imminent risk related to the child’s health condition)? If such research demonstrates that medical neglect is already being applied to health conditions associated with obesity and extremely obese children are already being placed in foster care, then there is an opportunity to learn from this process. That is, do the health conditions of these youth improve? Do they lose weight? When they are reunited with their caregivers, are the families able to maintain their healthier lifestyle choices that they learned while separated?

Data analyzing whether the circumstances under which foster placements are beneficial versus detrimental to youth have been to a large extent anecdotal, with some notable exceptions (e.g., Altshuler, 1998; Dubowitz, Feigelman, Harrington, & Starr, 1994; Tyler, Howard, Espinosa, & Doakes, 1997). Of note, some empirical data suggests that individuals who choose to foster youth without the intent to adopt may have less positive attitudes about parenting than individuals who do intend to adopt (Gillis-Arnold, Crase, Stockdale, & Shelley, 1998). For example, foster-only caregivers were more likely than potential adoptive caregivers to report that they would utilize corporal punishment. Moreover, the rate of substantiated maltreatment for 3- to 6-year-old children in nonrelative foster care (3.5%) was twice that of children placed with relatives (1.7%; Poertner, Bussey, & Fluke, 1999). Accordingly, removal of a child from the home is not necessarily a panacea, and the efficacy of such an approach depends on several factors.

Estimates vary with regard to the proportion of youth in foster care experiencing serious problems of adjustment, but regardless of how it is measured, foster placement does not necessarily equate to optimal or even better adjustment for children. By various estimates, approximately half of youth placed in out-of-home care by CPS experience clinically significant behavioral problems (e.g., Burns et al., 2004; Clausen, Landsverk, Ganger, Chadwick, & Litrownik, 1998; Leslie, Hurlburt, Landsverk, Barth, & Slymen, 2004). Work with adults also suggests variability in the extent to which foster care leads to better outcomes. For example, Schneider and colleagues (2009) reported that out-of-home placement during childhood or adolescence was associated with more mental health problems, poorer subjective health, lower levels of educational attainment, increased risk of smoking, obesity, poverty, and a reliance on public assistance in adulthood. That said, the bulk of this research is cross-sectional or retrospective, making it problematic to disentangle the extent to which foster care placement leads to new problems, exacerbates existing problems, or ameliorates, although not entirely, preexisting problems. Even so, the high rates of difficulties in some of the research to date is perhaps not surprising, given the multiple, additive, and interactive vulnerabilities experienced by many youth in foster care, including maltreatment, as noted earlier, as well as the emotional ramifications of being removed from the home (i.e., disruptions in family, school, peer relations, and community). In turn, prospective work suggests that several factors predict how youth fare in foster care placement, including child factors (greater cognitive and social competence), caregiver factors (greater stability), and maltreatment factors (less physical abuse; Proctor, Skriner, Roesch, & Litrownik, 2010).

In spite of national attention to the issue, little empirical attention has addressed the question of whether a child’s removal from the home and placement in foster care is an efficacious approach to the treatment of extreme childhood obesity in particular. Moreover, the limited data that do exist suggest that children in foster care may not only fail to lose weight but also gain weight. In one study, Hadfield and Preece (2008) reported that children in care in the United Kingdom were significantly more likely to be overweight or obese compared to children in the general population. For example, 35% of the children who came into foster care before 5 years of age became overweight or obese within the 3-year study period. The length of time in care, in turn, was positively associated with the likelihood of children being overweight or obese. Other work suggests similar trends toward obesity in adults with foster care histories in the United States. Women who experienced out-of-home placement during childhood or adolescence for example were more likely to be obese relative to women who did not experience out-of-home placements (Schneider et al., 2009). Importantly, some data does suggest that the interrelationship of obesity and foster care placement may depend, at least in part, on the type of placement. Ehrle and Geen (2002), for example, reported that youth in kin placements were more likely to be living in low-income homes with unemployed caregivers who did not have a high school degree and, in turn, were more likely to experience the aforementioned risk factors for obesity associated with low SES (see Shrewsbury & Wardle, 2008, for a review).

Accordingly, more empirical work is needed to determine whether the removal of a child from the home and placement in foster care is an efficacious treatment option, and such work may be approached in several ways. First, states that have already implemented foster care placement for extremely obese youth have the opportunity to assess children’s weight as well as broader physical, social, psychological, and academic correlates of obesity, before, during, and after placement. This will allow us to determine whether or not positive change occurs and for what outcomes in particular. Similarly, more work similar to the research noted earlier in the United Kingdom could certainly be conducted in the United States as well. That is, do extremely obese children who are placed in foster care in the United States evidence better outcomes (e.g., maintenance of current weight, weight loss, lifestyle changes) on average than those extremely obese children who remain home with their primary caregiver? If either of these research designs suggest that foster placement is significantly associated with improvement in a child’s weight, and/or broader physical and psychological health and health behavior, then such evidence would support CPS intervention and foster care placement may be efficacious intervention approaches.

A final direction for research is to examine the extent to which foster families and providers at institutional placements could be trained to ensure that youth are moving to a home environment that is going to be radically different with regard to weight control and reduction efforts than the home from which they were removed. Importantly, such work needs not only to examine the effect on the child’s physical health needs but also to prepare the family to help the child cope with the psychological, social, and academic sequelae of obesity. Notably, models exist for training foster parents to better meet the specific needs of foster children, including issues related to childhood trauma. For example, Dorsey’s Fostering Hope Project teaches foster parents the basic principles of Trauma-Focused Cognitive Behavioral Therapy (TF-CBT), an evidence-based intervention for helping youth cope with the aftereffects of trauma, behavior problems, and co-occurring difficulties (Cohen, Deblinger, Mannarino, & Steer, 2004; Deblinger, Lippman, & Steer, 1996; Dorsey, Cox, & Conover, 2011). With this model, foster parents trained in the principles and skills of TF-CBT are better equipped to foster youth with trauma and maltreatment histories, increasing the likelihood that youth removed from homes in which maltreatment was occurring can thrive in foster care settings. Although we are not aware of available data, “Fostering Health and Nutrition” is reportedly being developed to target family-level factors that affect poor health and nutrition for parents and preschool-age children in the foster care system in the state of Illinois (Helton, Fiese, & Diaz, 2013). Building upon the aforementioned findings regarding variation in the food environment for youth in kin versus nonkin placements, such programs may also be particularly helpful for those placements in kin and low SES settings (Ehrle & Geen, 2002).

Summary and Conclusion

In summary, a review of the existing evidence base does not yet seem to provide a robust case in support of CPS involvement in extreme cases of childhood obesity. That is, etiological data highlight that childhood obesity is likely the result of evolutionary, interactive, and unfolding processes that begin in utero and continue to be influenced by environmental factors at home, in the community, and at school. Accordingly, it is not clear that considering extreme child obesity as an issue of caregiver behavior, omission or commission, alone or primarily, makes sense conceptually. Perhaps even more importantly, little empirical attention has been devoted to determining whether the intervention option, CPS involvement, introduced by considering extreme obesity an issue of maltreatment, is an efficacious approach. Accordingly, we highlight the need for further empirical investigation of CPS as an intervention for extreme childhood obesity, in order to inform decision making, policy, and practice recommendations for this critical public health issue. To this end, we propose several interrelated lines of research including the following guiding questions: First, is it possible to better coordinate an efficacious, multidisciplinary approach to the prevention of childhood obesity? In addition, can we better facilitate the dissemination of and engagement in evidence-based treatment programs for childhood obesity? Third, is obesity a sign or symptom of maltreatment that would lead to CPS involvement for more traditional forms of maltreatment? Finally, is CPS involvement in cases of extreme child obesity an efficacious intervention option? It is our intention that these questions not only provide a framework within which to organize the existing literature but also to spark collaborative, transdisciplinary efforts that continue to move the field forward as such efforts are critical to enhancing our collective efficacy in the fight against childhood obesity and its lifelong health, economic, and societal implications.