Court-ordered placement for child obesity: What can you do to help?

by Ellyn Satter, Registered Dietitian and Family Therapist

Are you being called as an expert witness for a child being considered for placement based on his extreme obesity? Be ready ahead of time, and do careful strategic thinking. Your primary consideration is whether the child is being neglected; that is, is he in an unsafe environment? To answer those questions, do a complete weight-focused assessment.

Child welfare is paramount 

We, the health workers, courts, and social services people, are all committed to child welfare: protection of the child. But do a web search for Child Protective Services (CPS) and child obesity and you will see the opinions vary widely about the form that child protection should take: Parents arrested for child obesity, removing child for obesity is wrong; obesity is so bad that child removal is necessary.¹

I participated as an expert witness in a case that I wrote about in Your Child’s Weight: Helping without Harming.² The child was placed in foster care, weight loss was mandated by the courts, and the foster parents put the child on a severe weight-reduction diet. The tragedy was that the child’s weight was the least of his problems. He was a legitimate focus of CPS: His parents were neglecting him and not keeping him safe. He was put into foster care, not to protect him from neglect and endangerment, but to get him to lose weight. His foster parents were caring and wanted the best for him. However, because they were instructed, essentially, to starve him, they could not reach out to him and let him  feel nurtured. Because he sneaked and stole food, he did not feel worthy of their love. In short, imposing a diet in what could have been a healing foster setting for him turned it into a real mess for everyone. 

How can we avoid creating a mess?

Let’s imagine you are being called as an expert witness for a child being considered for placement based on his extreme obesity. Here is your primary consideration: Is this child being neglected? Is he in an unsafe environment? In order to answer that question, complicate the issue, not simplify it. Make the child the subject of the complete weight-focused assessment that I describe in Your Child’s Weight³ Appendix E: Assessment of feeding/growth problems. This assessment considers, from birth (to the extent that records are available):

• The child’s medical and physical history (including growth).
• Current and past patterns of nutrition and food selection.
• Psychosocial characteristics of the family in general and parents in particular.
• The child’s development, both past and present.
• Parent-child feeding dynamics.

Weight extremes grow out of extreme distortion

Do not under any circumstances participate in a hearing without having a clear agreement that you will do a complete assessment and be invited to share the results of that assessment in your written and/or verbal report to the court.

The child is being considered for placement based on extreme obesity. It is unlikely that such a weight extreme would grow out of genetics and a positive feeding environment. Genetics can allow, but is unlikely to cause such extreme obesity. Your assessment will likely show that the child’s weight has accelerated abruptly and/or substantially. Other records will suggest causes for that acceleration:  restrained feeding (e.g weight reduction attempts, either direct or indirect), poor feeding practices, stress, and/or a combination of these factors.⁴ Poor feeding practices are likely to grow out of family stress or neglect. Take note of when the weight acceleration occurred: This is likely to be the developmental stage when the child’s needs were most severely neglected. Subsequent restrained feeding may have been imposed in order to repair the weight acceleration, thus exacerbating it. Food insecurity, which may be reflective or independent of overall neglect, may exacerbate weight gain. Because it makes the child afraid of going hungry, food insecurity mimics restrained feeding, as do errors in feeding growing out of chaos in the home that undermines regular, reliable feeding times. 

Be skeptical and clear-sighted in your assessment

Do not take at face value what the parents tell you. The child’s extreme weight acceleration shows that something is seriously wrong, and you must identify what it is. What is your critical and considered judgment of the parents? The child’s safety and well-being are at stake. Are parents providing adequately for the child? Loving the child is not enough. Even abusive and/or neglectful parents love their child and will fight to keep him or her. Their child loves them back and longs to be reunited with them. Without careful and extensive intervention, families go back to their same old ways. 

Be credible in your recommendations for the child

The child has been referred for obesity, and the intervention, from the feeding dynamics perspective, is optimizing his or her feeding based on the Satter Feeding Dynamics Model and the Satter division of responsibility in feeding.⁵ Whether the child is placed at home or foster care, recommendations for that child’s care must include parents taking strong and consistent leadership with the what, when, and where of feeding and giving the child unambiguous autonomy with the how much and whether of eating. Such authoritative feeding will support the child’s own growth and development. Determine whether parents can responsibly and reliably act on your recommendations. Keep in mind that it is not realistic for a parent to starve a child to force weight loss, and that parent’s previous “failures” in that respect could be more an indication more of parental strength than weakness. You might have to testify that parents can not act on behalf of the child and that s/he should be placed in foster care. Referral to foster care must include the clear proviso that the child be provided for with feeding management in accordance with your recommendations. That is foster parents take strong and consistent leadership with the what, when, and where of feeding and giving the child unambiguous autonomy with the how much and whether of eating.  

The everybody knows effect

The main problem you will have in communicating with court personnel is breaking through the simplistic and nonsensical everybody knows effect relative to child obesity. Everybody knows that children get too fat because they are overfed and under-exercised. Everybody knows that parents’ having the “wrong foods” in the house is to blame and that parents having those foods is a clear indicator of neglect. Everybody knows that the home must be purged of certain foods (and inspections run to make sure the purge happens). Everybody knows that the child must be made to eat less and move more. Everybody knows that if a child becomes or stays fat it is because parents fail to get the child to eat less and move more. Therefore, if a child is fat, everybody knows that parents have failed and are continuing to fail the child and that child must be placed in foster care. Once he is there, everybody knows that child must be underfed and over-exercised in order to get him to lose weight. 

Position yourself strategically

The everybody knows effect mandates your being strategic in your involvement. If you go ahead without strategic positioning, you will get hurt, and you won’t do the child any good. Because juvenile court personnel may have a simplified agenda based on the everybody knows effect, they are likely to talk around you and trip you up, and you will be so undermined that you won’t be able to interest them in considering the complexity of the issue.

1. Do not under any circumstances participate in a hearing without having a clear agreement that you will do a complete assessment and be invited to share the results of that assessment in your written and/or verbal report to the court.
2. Get the backing of your supervisor/administrator.
3. If #1 and #2 are not in place, do not agree to participate in the process.  

Do preventive education

It is better to start working on this issue before it comes up. My conversations with attorneys and child protective workers indicate that the place to start is with education of Juvenile Court judges, attorneys, and Human Services Child Protective Workers. Being able to understand the complexity of child obesity will help those child advocates protect themselves from the everybody knows effect. Having taken off the blinders relative to the issue of child obesity, those worthy practitioners can consider the child’s social, emotional, and nutritional needs, and avoid mandating unnecessary and counterproductive placement for weight loss. However, even if you have done your homework in educating officers of the court, only agree to testify if stipulations 1 and 2, above, are in place. 

ESI is not in a position to take the active role with the courts described in this newsletter. However, through the ESI mentoring program, an ESI faculty member can support you in doing strategic thinking and working through the critically important assessment process.