Is childhood obesity a child protection concern?

Background The question as to whether childhood obesity should be considered a child protection issue has divided commentators, with many questioning whether a child should be removed from parents who do not seek to reduce their child's weight, where significant obesity is identified. This divide is reflected in the social work profession where there is resistance to a role focused on bodily surveillance, whilst also acknowledging the need to investigate neglect where evidence exists of a clear parental failure to manage a child’s diet, health and fitness. Similar divisions exist in the medical profession and debates are taking place in Australia and the US but with little research to inform policy and practice. In the UK, practice varies with a consideration of obesity being incorporated in some multi-agency child protection procedures but with no mention in others and little research to explain variations. In the absence of evidence the most influential guidance remains a paper by Viner et al (2010), which concludes: • Childhood obesity alone is not a child protection issue • Failure to reduce overweight alone is not a child protection concern • Consistent failure to change lifestyle and engage with outside support indicates neglect, particularly in younger children • Obesity may be part of wider concerns about neglect or emotional abuse • Assessment should include systemic (family and environmental) factors It is this framework which is both widely quoted and incorporated into the child protection procedures of some local authorities but there appears to be no research which has tested its usefulness or applicability in practice. This research project was funded by NIHR CLAHRC YH and was conducted by staff from The Department of Social Work, Social Care and Community Studies and Centre for Health and Social Care Research at Sheffield Hallam University, Doncaster MBC, Rotherham MBC and School of Human and Health Sciences Huddersfield University. Ethical approval was provided by Sheffield Hallam University and research governance from Doncaster MBC. A project advisory group was set up from health and social care professionals which met virtually at the outset of the project, to guide the direction of the research, interviewing content and protocol, and to inform sampling. Aims and Objectives The research aimed to understand whether childhood obesity is a child protection concern and had three objectives: • To explore the current and past practice of staff working within child protection and obesity services regarding child protection and obesity • To explore staff perceptions of childhood obesity as a child protection issue using interview and focus group methods • To explore the use of the Viner et al (2010) framework for action to understand child protection concerns for children who are obese. Design and Methods The research project conducted semi-structured interviews (N23) and facilitated focus groups (N3, N24) involving key stake holders from social care, health and education services. The professional roles of participants ranged from professionals involved in early help and family support, through to investigation and middle and senior management. Doncaster Council (DC) supported the recruitment of participants, through dissemination of information leaflets, email contact and the provision of interview facilities. All of the interviews and focus groups were undertaken in Doncaster in South Yorkshire, however the research was by no means an evaluation of current or past practice within the authority and participants were able to reflect on their experiences across geographic areas and professional roles and responsibilities. Framework Analysis methods were used to generate categories, codes and themes that capture the experiences, views and perceptions of the participants. The research team took a collective approach to the analytical process in order to develop the thematic framework. Findings The framework comprised of seven key themes: Obesity: The short and long term impacts that obesity may have on a young person's physical and psychosocial health were acknowledged. Social factors relating to culture and poverty were also seen as contributing factors. Parental attitudes and perceptions were seen as playing a key role in recognising and responding to childhood obesity. The clinical nature of assessing and identifying obesity is complicated for non-health professionals. Thresholds: For child protection services to undertake work, requests need to meet a severity threshold for interventions to occur. Thresholds were nuanced and complex and could act as inhibitors to providing services. The threshold operated not only as a line that had to be crossed in order for a referral to be accepted by social services but also in respect of individual practitioner thresholds regarding personal views and values regarding obesity, different agency thresholds, referrals for different services within an agency and also between agencies. Child Protection: Respondents were divided as to whether child obesity was a child protection concern. For some the impact of obesity on long and short term outcomes for children made obesity unequivocally a child protection concern, yet for others excess weight itself was not sufficient. Where there was more common ground was in respect of the links between obesity and parental neglect. This could be in the form of associated factors such as failure to attend school or mental health issues but also for many respondents a failure on the part of families to engage with support plans and services offered. Those services were seen as a continuum of intervention levels from universal to statutory with child protection and legal interventions part of that continuum rather than a separate entity. A child protection approach could act as a catalyst for families to take up support as well as a gateway to more financially expensive and intensive support offers. Viner Framework: The Viner framework was developed as a means of understanding and working with child obesity as a child protection issue. Almost all participants had no awareness of the Viner framework. Overall the framework was welcomed as a useful tool, with the caveat that over reliance on a framework can lead to over simple assessment. The framework was not seen as overcoming problems inherent in measuring and identifying obesity, and not identifying the association of obesity with sexual abuse. Good Practice: Good practice was seen as beginning with a holistic understanding of obesity and its impact followed by a multi-agency approach including health, school and social care. Direct work with the whole family is given prominence in achieving change, both within and without a child protection context. Family involvement in the development and implementation of that work in a way that empowers but does not stigmatise was identified as a goal. Parental education was seen as important as part of a preventative approach and in sustaining change. Challenges for Practice: Challenges to practice included structural issues such as a lack of funding for preventative services and a scarcity of targeted services for disadvantaged groups. Psycho-social barriers to families accepting support were identified such as poverty impacting upon individual behaviour. Multi–agency working was a source of frustration with a lack of clarity regarding roles and responsibilities. Direct work with families was central but could be contentious. Challenges included the potential reinforcement of unhealthy eating patterns and the need to balance risk management with building trust and relationships in order to bring about change. Suggestions for Future: Suggestions included training on obesity and service availability, and providing a framework and procedures to guide practice. Evidence on short and long-term outcome measurements was identified as a deficit. More research and dissemination of findings on outcomes and what works regarding interventions is required. Conclusions This research has offered a unique insight into current multi-agency practice in respect of child obesity and child protection. Whether obesity alone can be a child protection concern is contested. Families who fail to recognise that child obesity is harmful to children and the failure of families to engage in support services was thought to potentially constitute neglect. When making judgements about child obesity and levels of harm, personal views about obesity and value judgements regarding parenting and children were as important, if not more so, than factual knowledge. These views come to the fore explicitly in threshold judgements and subsequent referral behaviour regarding identifying and acting on potential and actual significant harm. The services offered to and accepted by service users in respect of child obesity are both influenced by and a consequence of those threshold judgements. Training regarding the identification, assessment and implications of child obesity was required. Given an acknowledgement of a multidisciplinary approach to child obesity assessment and service delivery being most effective, multidisciplinary training could also be most useful. Many would welcome a framework and procedures to guide, but not dictate, practice where child obesity may constitute significant harm and become a child protection concern. Direct obesity focussed work with children and families is seen as key to bringing about change whether through universal services, family support or child protection statutory interventions. More research is required on the short and long-term effectiveness, outcomes and financial viability of those interventions to guide strategic and front line service delivery.