An 8-year-old Ohio boy is removed from his home and placed in foster care by the Cuyahoga County Department of Children and Family Services because he weighs more than 200 pounds. The agency’s reasoning is that the boy’s health is at risk for serious medical conditions and that his mother’s efforts to address his problems have been unsuccessful. From a mental health perspective, is this action in the boy’s best interests?
I think not.
By Dr. Richard Perry
The case involved a third-grader who reportedly was "a normal elementary school student who was on the honor roll and participated in school activities," according to an article in the Cleveland Plain Dealer. The only medical problem for which he was being treated reportedly was sleep apnea.
We are in the midst of a national public health crisis with estimates that one-third of Americans adults and children are overweight or obese. Authorities defended themselves by stating that they had tried to work with the boy’s mother and although his weight had come down slightly at one point, it was again on the rise at the time of the removal. The mother’s lawyers and a juvenile public defender argued that the boy’s medical condition did not pose an imminent threat, that his mother was complying with the treatment of sleep apnea, and that the boy was involved in a hospital weight reduction program. One criticism was that no policy was in place to cover such cases. The boy’s mother noted that she, the boy’s father, and other family members were overweight but that her 16-year-old son was not.
The outcry against the agency’s removal of the child included charges of hypocrisy toward a culture that allows the food industry to market unhealthy foods to children.
I agreed, after reading the article, with those who criticized the handling of the case because of the effects it could have on the child’s mental health and on the mother-child relationship. Any placement, such as in a pediatric inpatient unit or specialized residential program, would have been preferable.
Some of those who were critical of the decision argued that the boy’s health was not in imminent danger. But what did that mean? Wouldn’t it be irresponsible to wait for a child’s health to be so compromised as to become a medical emergency?
A few weeks after the initial article was published, the Plain Dealer reported that the county executive stated that the boy’s removal was done because of a "physician’s referral" and that the case was a medical issue. He noted that a residential weight loss program was considered, but the nearest one was too far away. On Dec. 14, the newspaper reported that the boy was ordered by court to go live with an uncle in Columbus and that his mother could visit at any time and would have him home for a week at Christmas time. I note that Cleveland is more than 100 miles away from Columbus. At the time of that article, the boy weighed 192 pounds. He turned 9 in December. As of this writing, the case was to be reviewed in court in February 2012.
Obesity and overweight are included in the ICD-9 and ICD-10 but not in the DSM-IV – nor are those conditions proposed to be included in the DSM-5. Nonetheless, psychiatrists certainly confront the issue in our practices. It would seem that it is our obligation, along with our colleagues in other specialties, to guide our patients to a healthy lifestyle because of the effect that being very overweight has on a person’s health and self-esteem. In addition, we have to be aware of this issue as it relates to our prescribing of medications to patients who already are overweight or with the administration of medications that can cause or add to metabolic problems.
Two fairly recent articles might offer guidance to psychiatrists on this issue. One, by Dr. Ann E. Maloney, of the Center for Clinical and Translational Research in Scarborough, Maine, offers an overview of the causes, and the physical and mental repercussions and treatment of childhood obesity (Child Adolesc. Psychiatr. Clin. N. Am. 2010;19:353-70). Because child and adolescent psychiatrists often encounter children who are obese, we might be asked to work with primary care physicians and other specialists to treat these patients. The other article, by Amanda S. Bruce, Ph.D., and her colleagues at the University of Missouri, Kansas City, reviews the correlation between the activity of neural networks and the ability to control appetite. Studies show a growing balance during development between drive, motivation, and impulsivity as it relates to food cues and the ability – naturally lacking in children – to inhibit impulses and delay gratification (Prev. Med. 2011;52[Suppl. 1]:S29-35).