Childhood obesity – a safeguarding issue?

This is part of our safeguarding insights section.  Our aim is to provide you with a broader understanding of a specific topic through a researched and referenced article that contributes towards your professional development and ensures that you can support your staff accordingly.

15 minute read

DSLs and Safeguarding Teams

Introduction

The implications of childhood obesity have been recognised for a number of years, with this leading to the government developing a plan for action.  Some of the actions within the plan will be familiar to all of us, for example the introduction of a sugar tax (or Soft Drinks Industry Levy) in April 2018, a general push to reduce the amount of sugar in foods and active advertising of the Change4life campaign.  For many public sector settings there has also been a push to make healthier options available, with schools being either mandated or expected to comply with certain standards.

The reason for this is clearly shown through statistics.  A House of Commons Library report (August 2019) identifies that:

• 9.5% of reception age children (age 4-5) are obese, whilst a further 12.8% are overweight
• 20.1% of 10-11 year olds (Year 6) are obese and a further 14.2% are overweight.

This translates to potentially two children in every reception class being obese with a further 3 being overweight, and 6 children in every Year 6 class being obese and a further 4 being overweight.  The government illustrate that this then translates into adulthood with “58% of women of childbearing age (16-44 years) being either overweight or obese in 2014” (Childhood obesity: applying All Our Health, 2019).  Therefore, whilst the statistics relate to primary school children, it is clear that this is an issue that affects children of all ages.

The House of Commons Library report (2019) identifies a clear link between deprivation and obesity, stating:

Children living in deprived areas are substantially more likely to be obese. Among reception (age 4-5) children, 6.4% of those in the least deprived areas are obese compared with 12.4% of those in the most deprived areas. In Year 6 (age 10-11), 13.3% of children in the least deprived areas are obese, compared with 26.7% in the most deprived areas. So in both age groups, children in the most deprived areas are approximately twice as likely to be obese. Rates of severely obese children are around three times higher in the most deprived areas.

Whilst there are those who suggest that one of the main instruments for measuring obesity, Body Mass Index, is flawed and not culturally reflective, there is still a significant issue that needs to be addressed (Huffington Post, 2020).

The impact of obesity is widely known as well, with many of the issues being summarised in a Public Health England infographic.

Does a line need to be drawn, and if so where?

But does childhood obesity mean that there are safeguarding concerns?  As the infographic demonstrates, there are significant impacts on children and young people from being obese with long term consequences for physical and mental health as well as potential impacts on adult life (e.g. reduction in earning ability).

Obesity is not mentioned as a safeguarding issue in Keeping Children Safe in Education (2019), and the only explicit mention of food in any of the categories of abuse is in the definition of neglect where failure to provide adequate food is listed as an indicator (Working Together 2018, page 104).  A quick look at the first ten current threshold documents for safeguarding Boards that I could find on the internet revealed that only three mentioned obesity as a child protection matter and in all those that did this was quantified by the word “severe”.

This leads to the question as to whether staff in your setting even consider obesity a potential safeguarding issue, and if they did would they feel comfortable raising it?  On a personal level, would you know what constitutes severe obesity?

The associated quandaries even within the medical profession were highlighted by Viner et al. (2010).  They highlighted that a motion was put to the British Medical Association in 2007 suggesting the obesity in under 12’s should result in legal protection for the child (the motion was rejected).  They then highlight opposing evidence from UK research in 2010 which identified that four out of five obese children in the study had rare genetic condition that was linked to overeating.  Are parents to be seen as agents of change or as the cause of the child’s obesity?

Child F1

Child F1 was the second of four children.  Their mother had arrived in the UK as a refugee from Eastern Europe prior to F1’s birth.  The family became known to Housing Services in 2009 through being victims of domestic abuse and by 2010 the child’s father lived separately.  At three years old, F1 was considered to be morbidly obese (on the 99.6^th centile).  Child F1 died from a heart condition aged 13 which medical reports stated was exacerbated by their morbid obesity.  An article in the Independent (Matthews-King, 25^th May 2018) sets morbid obesity as being a condition that significantly increase health risks including type 2 diabetes, heart disease, strokes and cancer.

Manchester Safeguarding Children Board (MSCB) commissioned a Serious Case Review (SCR) which was published in 2018.  The SCR overview report identifies that there were numerous missed opportunities during the 10 years between F1 being identified as being morbidly obese and their death.  The report states:

At the heart of this SCR is evidence of professional uncertainty and hesitancy about addressing childhood obesity and considering it as a possible indicator of abuse and neglect. There were indications here of professional paralysis in the face of a serious issue which had the capacity to impact negatively on many aspects of a child’s development. […] The review highlights that childhood obesity impacts negatively in the short and long term and is a concern which requires serious thought, assessment, analysis and action and professionals need to be equipped to provide an appropriate response. (p.5)

The report identifies that although professionals including education and health, were aware that child F1 was morbidly obese, there was “never a clear plan of action”, with the issue “consistently treated as primarily a health concern” (para. 3.8, page 17).  The implication of this in F1’s case was that professionals were not clear with F1’s mother about what was expected.  The report also notes that:

There was evidence that this situation was a safeguarding concern which indicated a primary cause of neglect for the obesity. There was evidence of some professional anxiety more broadly about whether a safeguarding referral regarding childhood obesity would be taken seriously and accepted. The experience of the professionals was that it would not be. (p.18)

In the case of F1, the review found that the lack of professional knowledge, coupled with professional sensitivities to raising concerns with parents about their child’s weight, were compounded by F1’s mother being challenging towards professionals.  This had the implication that any work undertaken with the mother was focused on keeping the mother on side as opposed to addressing problems direct.  The report also indicates that cultural stereotyping may have been a feature, with some professionals seeing the obesity as potentially linked to the mother’s cultural norms.

A case of neglect?

As Viner et al. (2010) identify, obesity can be as the result of abuse and can be difficult to treat.  Their argument is that it is not necessarily the obesity that is the child protection issue, but how the parent is acting in relation to the obesity that is the determining factor.  If the parent is not acting to make changes to the child’s lifestyle to promote healthier options, then this can come within the definition of neglect.

Working Together (2018) defines neglect as:

The persistent failure to meet a child’s basic physical and/or psychological needs, likely to result in the serious impairment of the child’s health or development. (p.104)

Taking the example of F1, the review found evidence that the mother was persistently failing to meet F1’s basic needs and that this seriously impaired his health ultimately leading to his death.  This included:

• Between the ages of 3 and 13, F1’s mother repeatedly missed appointments for F1 with medical professionals.
• Mother was diagnosed with a heart condition and advised to lose weight. She reportedly lost a considerable amount, demonstrating an understanding of the dietary and lifestyle changes required to get to a healthier weight.
• When challenged about poor school attendance, F1’s mother did not accept that any of the health issues that the were reporting were linked to F1’s weight and stated she provided a healthy diet for the children, with the problem being that F1 would overeat – this was in contradiction to what the school had seen on a daily basis (F1 was seen to be concerned about his weight).
• When F1 attended a Change4life group at his secondary school it became clear that F1 was having over 2000 calories before lunch, with this including a takeaway as a second breakfast. F1 told staff that they did not want their mother to know that they were attending the group as they did not think that their mother would want them to.
• When F1 was in hospital immediately prior to his death, his mother was continuing to refuse to accept dietary advice and bringing in take away food for F1 to eat.

With hindsight this can present as a very clear picture, however what happens when we are involved on a day to day basis?

Viner Framework

The 2010 article by Viner et al. is seen as setting out a framework in which professionals can operate, although as with any framework there is a proviso that it should not be over relied on as this could lead to an overly simply assessment (Nelson et al., 2018).

Adapted from Viner et al. (2010)

• Childhood obesity alone is not a child protection concern – Obesity has many causes and its complexity means that attributing the cause to neglect by parents is not possible. However, we should consider that abuse and / or neglect may be a contributing factor.
• Failure to reduce overweight alone is not a child protection concern – Medicine is not at a stage where every child will lose weight following management programmes. If there is engagement from all sides, then criticism is unrealistic.
• Consistent failure to change lifestyle and engage with outside support indicates neglect, particularly in younger children – as with any medical condition, if the parents actively fail to engage with the process despite significant support, or are actively subverting the process then there should be consideration of whether the criteria for neglect is met.
• Obesity may be part of wider concerns about neglect or emotional abuse – it is important that we look at the situation in the whole and ask, “what else am I seeing here?” Are there other concerns of which obesity is just one part?
• Assessment should include systemic (family and environmental) factors – What is the capacity of the parent to understand and respond to the child’s needs. What do we know about the context the child is in?

Research with practitioners by Nelson et al. (2018) showed that the framework provides a starting point and does not necessarily answer questions about what level of obesity should be present to trigger concerns initially.

A psychosocial approach

As identified by the review in relation to F1, traditional obesity management has focused on dietary advice and exercise, however there is now a body of evidence that suggests that many other factors can influence childhood obesity.  The research by Nelson et al. (ibid.) echoes this, with the following being areas that practitioners themselves identified:

It is therefore important that we consider what external influences there are and how these may be impacting on the child and the parent’s physical and mental health and their ability to function daily.  Through consideration of this information, as well as the approach of the parent towards the child’s obesity, it is then possible to determine where the response should lie, be that through early help, a referral to Children’s Social Care on a child in need basis or as a child protection matter.

A psychosocial approach also allows us to consider cultural issues and whether there are cultural aspects which are influencing a family’s attitudes towards food and body size.  However, as with all cultural issues, their presence should not mean that we turn away from the needs of the child.

Summary

Whether obesity is a safeguarding issue or not is very contentious, however as we have seen there are times when it can be a safeguarding matter that needs appropriate referrals to be made.  In this insight we have provided the outlines of a framework and evidenced the need to consider the child as a whole.  Using this approach, we believe that the identification of whether obesity is an issue that needs following up becomes more manageable as it is translated into processes that we know and understand.  This is not to say that these are the only approaches, however it is important that regardless of the approach we take, obesity and any resultant issues are identified appropriately.  Obesity is not just a matter for health colleagues to follow-up and as with all concerns in relation to children, there is a need for all professionals to look at what they know and challenge where necessary.

What to do…

The following questions will help your school to determine when there is cause for concern, and what to do. Early intervention is important and will help build a picture over time if your concerns continue to grow.

1. Is there a concern for a child’s weight? What do you know at present? How is it impacting on the child (movement, diet, social relationships, identity, self-esteem, self-care skills, financial)
2. Have you talked to the child and the family? Do they share the concern? What do they see as the background – is there a wider family issue, or particular factors that contribute to over-eating such as attachment issues, family boundaries, or as a response to grief? What are the family doing to resolve the issue and would they like help? Who else is involved? Can you obtain consent to bring professionals together to work on the problem? Ensure there is a health assessment to identify any potential underlying health issues and record the actions taken and any concerns in an effective chronology and consider the need for a shared assessment in line with your local safeguarding children partnership approach.
3. What is contributing to the problem? Consider the psychosocial questions above. Is this a problem in the wider community and part of the solution is a whole school approach? How might issues of income or social isolation impact on your plan?
4. What additional advice and support is required? Have a clear plan to intervene with targets around weight and behaviour agreed with the child, family, health professionals and school. What would success look like? At what point would your concerns rise further?
5. Drift is a particular danger in all cases of neglect. Have a clear and realistic timescale from the outset and regular monitoring meetings to evidence progress or otherwise. If the problem continues to grow, review the actions you have in place to try to make things more effective. If the child’s obesity is persistently not addressed, your actions are unsuccessful and the parents’ actions not reasonable so that it is likely to cause the child severe and persistent harm, then this is neglect and will require a referral to children’s social care. Your chronology and a multi-agency assessment of the likely harm and effectiveness of work undertaken to date will be crucial.

Members can contact Safeguarding Network for free initial advice around these issues.

Final thought

With one of the key pieces for this insight being the serious case review related to F1, it is important to note that there were two other key issues that the review identified as being present.

• The voice of the child not being heard and understood – we saw earlier that there was an occasion when F1 said that he did not want his mother to know that he was on the Change4life programme as he did not think that she would approve. Throughout the time that professionals were involved with the family there is little information about what life was like for F1 and little support for his help seeking behaviour – i.e. his voice was not heard.
• Agencies working in silos – Throughout the review there was evidence of a number of different agencies working with the family, but little information being shared, or concerns being escalated to others. The review found that had this been done at key points there may have been a different outcome.

There is of course a danger that we become hardened to these last two findings, as they seem to be a feature in every case review that is completed.  It is however a fact that they are a feature which demonstrates the need to continue to focus on these areas.  In relation to working with children where obesity is a concern, the importance of hearing the voice of the child and partnership working is crucial to ensure that concerns are identified and addressed early.