Judicial Intervention For Morbidly Obese Children: An Interesting Case Interesting Case Presentation Saint Francis Hospital Dept. of Pediatrics Jay E

Judicial Intervention For Morbidly Judicial Intervention For Morbidly Obese Children:Obese Children:

An Interesting CaseAn Interesting Case

Interesting Case PresentationInteresting Case PresentationSaint Francis Hospital Dept. of Pediatrics Saint Francis Hospital Dept. of Pediatrics

Jay E. Sicklick, Esq. & Lisa KechejianJay E. Sicklick, Esq. & Lisa Kechejian

MEDICAL-LEGAL PARTNERSHIP PROJECTMEDICAL-LEGAL PARTNERSHIP PROJECT

October 26, 2007October 26, 2007

Presentation GoalsPresentation Goals

Introduce the “obesity dilemma”Introduce the “obesity dilemma” Provide a case example of childhood Provide a case example of childhood

obesity – in the child protection obesity – in the child protection contextcontext

Overlay the legal backgroundOverlay the legal background Query - when do you request “state Query - when do you request “state

intervention?”intervention?” Invite discussion re “what is the Invite discussion re “what is the

appropriate intervention protocol?”appropriate intervention protocol?”

The ProblemThe Problem

The Threshold QuestionThe Threshold Question

When does obesity become a child When does obesity become a child protection issue for the clinician? protection issue for the clinician?

OR …OR … How out of control do things have to How out of control do things have to

get before you call DCF when dealing get before you call DCF when dealing with a morbidly obese child? with a morbidly obese child?

Case StudyCase Study

Brittany T:Brittany T: Age 8 – morbidly obeseAge 8 – morbidly obese 237 lbs237 lbs

BMI > 50BMI > 50 Co-morbidities: gallstone, excessive fat Co-morbidities: gallstone, excessive fat

in liver, sleep apnea, acanthosis in liver, sleep apnea, acanthosis nigricans, signs of depressionnigricans, signs of depression

Father confined to wheelchair/mother > Father confined to wheelchair/mother > 430 lbs. in April ’06430 lbs. in April ’06

Case Study (cont.)Case Study (cont.)

Brittany:Brittany: PCP indicates significant non-compliance PCP indicates significant non-compliance

with dietary instructionswith dietary instructions ““Threats” made on several occasions to Threats” made on several occasions to

call child welfare officials? call child welfare officials? Parents seem “incapable” of controlling Parents seem “incapable” of controlling

Brittany’s weight, but really love herBrittany’s weight, but really love her Brittany will be emotionally devastated Brittany will be emotionally devastated

if removed from home…if removed from home…


What is the appropriate decision? What is the appropriate decision? Who decides when enough is Who decides when enough is enough? enough?

Do you think that removal and Do you think that removal and commitment is appropriatecommitment is appropriate

Is termination of parental rights a Is termination of parental rights a justified action? justified action?

Source: Conn. Gen. Stat. § 17a-101a.

Legal ContextLegal Context

Mandated Reporting RequirementsMandated Reporting Requirements Reasonable Cause to Suspect:Reasonable Cause to Suspect:

AbuseAbuse NeglectNeglect Child w/non-accidental physical injury or one Child w/non-accidental physical injury or one

at variance w/history givenat variance w/history given Child At Imminent Risk of HarmChild At Imminent Risk of Harm

Source: Conn. Gen. Stat. § 46b-120

Legal BackgroundLegal Background

Abuse:Abuse: Inflicted w/physical injuries other than Inflicted w/physical injuries other than

by accidental means, by accidental means, Injuries at variance w/history givenInjuries at variance w/history given Condition result of Condition result of

MaltreatmentMaltreatment such as malnutrition, sexual such as malnutrition, sexual molestation/exploitation, deprivation of molestation/exploitation, deprivation of necessities, emotional maltreatment or cruel necessities, emotional maltreatment or cruel punishmentpunishment

Source: Conn. Gen. Stat. § 46b-120

Legal Background (cont.)Legal Background (cont.)

Neglect:Neglect: AbandonmentAbandonment Denial of proper care and attention, Denial of proper care and attention,

physicallyphysically, , emotionally or morallyemotionally or morally Living under conditions, circumstances, Living under conditions, circumstances,

associations associations injurious to the well being injurious to the well being of the child …of the child …

Has been abused.Has been abused.

A Public Health Crisis? A Public Health Crisis?

Source: NCHS 2004 NHANES Data

A Public Health Crisis?A Public Health Crisis?

A Public Health CrisisA Public Health Crisis

1999-2002 Data on Obesity (CDC):1999-2002 Data on Obesity (CDC): Non-Hispanic black (21%) & Mexican-Non-Hispanic black (21%) & Mexican-

American adolescents (12-19) (23%) American adolescents (12-19) (23%) more likely to be overweight than more likely to be overweight than Whites (14%)Whites (14%)

Another 15% children (6-19) considered Another 15% children (6-19) considered “at-risk” of becoming overweight (BMI “at-risk” of becoming overweight (BMI between 85between 85thth-95-95thth percentile). percentile).

Since 1994 overweight youths Since 1994 overweight youths increasing to higher levelsincreasing to higher levels

Other CasesOther Cases

Christina C. (California)Christina C. (California) 13 y.o.13 y.o. Weighed 680 lbs. when died of CHFWeighed 680 lbs. when died of CHF Mom consented to dropping out of Mom consented to dropping out of

schoolschool Found dead in living roomFound dead in living room Mom found guilty of misdemeanor child Mom found guilty of misdemeanor child

abuse abuse


L.T. (Iowa)L.T. (Iowa) 10 y.o. girl10 y.o. girl 290 pounds & yeast infection growing from 290 pounds & yeast infection growing from

skin folds in abdomenskin folds in abdomen Semi-compliant momSemi-compliant mom

Drove to appts. Drove to appts. Would not send to residential Would not send to residential Chronic depressionChronic depression

Adjudicated as a “CINA”Adjudicated as a “CINA” Placed in state care for residential t/ment & Placed in state care for residential t/ment &

foster care. foster care.

Source: Iowa Code § 232.2(6)(f) (1991)


CINA Statute (IOWA)CINA Statute (IOWA)

“ “ Child in need of assistance”Child in need of assistance” means an means an unmarried child who is in need of medical unmarried child who is in need of medical treatment to cure or alleviate serious treatment to cure or alleviate serious mental illness or disorder, or emotional mental illness or disorder, or emotional damage as evidenced by severe anxiety, damage as evidenced by severe anxiety, depression, withdrawal or untoward depression, withdrawal or untoward aggressive behavior toward self or others aggressive behavior toward self or others and whose parent, guardian, or custodian is and whose parent, guardian, or custodian is unwilling or unable to provide such unwilling or unable to provide such treatment.treatment.


Indiana (Indiana (Corey ACorey A.).) 5 y.o. boy5 y.o. boy 138 lbs. 138 lbs. Other health conditions including Other health conditions including

respiratory distress (r/q oxygen) & sleep respiratory distress (r/q oxygen) & sleep apneaapnea

Concurrent conditions in house (garbage, Concurrent conditions in house (garbage, roaches, rats, rotting foodroaches, rats, rotting food

State intervened due to neglect State intervened due to neglect While in foster care lost 50 lbs.While in foster care lost 50 lbs.


Corey ACorey A::Court ruling – commitment: Court ruling – commitment: Intervention appropriate b/c M.D.’s Intervention appropriate b/c M.D.’s

recommendations ignored (diet) “too recommendations ignored (diet) “too hard to follow.”hard to follow.”

Parents resentful and complained about Parents resentful and complained about being instructed how to feed Coreybeing instructed how to feed Corey

Parents directly violated diet by giving Parents directly violated diet by giving fast-food meal fast-food meal while hospitalizedwhile hospitalized … …


Anamarie M. (New Mexico)Anamarie M. (New Mexico) 3 y.o. 3 y.o. 120 lbs. & 3’6” tall120 lbs. & 3’6” tall Referral made to Child Welfare agcy …Referral made to Child Welfare agcy …

Agcy ordered special diet, exerciseAgcy ordered special diet, exercise M.D. recommended liquid diet – parents M.D. recommended liquid diet – parents

non-complaint non-complaint Parents maintained condition Parents maintained condition

“medically” caused“medically” caused State CW agcy intervenedState CW agcy intervened

Other CasesOther Cases Anamarie (cont.)Anamarie (cont.)

Outcome – returned to Outcome – returned to mom three months mom three months after period of after period of commitmentcommitment

Controversial decision Controversial decision … see … see www.geocities.com/lawww.geocities.com/laurie_avocado/Anamariurie_avocado/Anamariee

Parents sued the state Parents sued the state of N.M.of N.M.

At 7: 5’1” & 200 lbs., At 7: 5’1” & 200 lbs., w/bones of 14 y.o. w/bones of 14 y.o.


Pennsylvania (D.K.)Pennsylvania (D.K.) 16 y.o. boy16 y.o. boy 451 lbs; 5’3”451 lbs; 5’3” Mom obeseMom obese PCP ordered inpatient stay due to PCP ordered inpatient stay due to

Enlarged liver, hypertension, respiratory Enlarged liver, hypertension, respiratory difficulty, insulin resistance, sleep apnea, difficulty, insulin resistance, sleep apnea, knee painknee pain

Mom did not visit in hospitalMom did not visit in hospital Referral and court intervention … Referral and court intervention …

adjudged adjudged dependentdependent


D.K. Court rationale:D.K. Court rationale:

““[Child welfare agency] would not be [Child welfare agency] would not be justified by intervening simply because a justified by intervening simply because a child was overweight, or did not simply child was overweight, or did not simply engage in a healthy and fit lifestyle. engage in a healthy and fit lifestyle. Rather, the obesity must be of a severe Rather, the obesity must be of a severe nature reaching the life threatening or nature reaching the life threatening or morbid state, which has also manifested morbid state, which has also manifested itself in physical problems, such as those itself in physical problems, such as those present here, or mental problemspresent here, or mental problems…”…”


Texas (G.C.)Texas (G.C.) 4 y.o. boy4 y.o. boy 97 lbs. 97 lbs. PCP request blood sample for diagnostic PCP request blood sample for diagnostic

tests – parents refused. tests – parents refused. Parents changed PCP twice Parents changed PCP twice Child hospitalized in 1996 – difficulty Child hospitalized in 1996 – difficulty

breathing & mildly enlarged heart (CHF)breathing & mildly enlarged heart (CHF) Child removed and placed in foster careChild removed and placed in foster care


G.C. (cont.)G.C. (cont.) Outcome: continued non-compliance = Outcome: continued non-compliance =

TPRTPR Refusal to work with court ordered Refusal to work with court ordered

“homemaker” as role model final straw“homemaker” as role model final straw

Connecticut PrecedentConnecticut Precedent

In re Kenneth E. In re Kenneth E. 2006 WL 2773444 2006 WL 2773444 (Conn. Super., 2006)(Conn. Super., 2006) 15 y.o. boy15 y.o. boy 346 lbs. 346 lbs. Parents “failed to recognize problem” but Parents “failed to recognize problem” but

“unintentional.”“unintentional.” Court denied removal w/parents promise Court denied removal w/parents promise

to comply but ordered to comply but ordered protective protective supervisionsupervision

Happy ending … child lost 56 lbs. in one Happy ending … child lost 56 lbs. in one summersummer


Brittany T:Brittany T: Mandated programs to address obesityMandated programs to address obesity

Attendance at gym classes 3 days/weekAttendance at gym classes 3 days/week General non-complianceGeneral non-compliance Absent from school 48 out of 68 school daysAbsent from school 48 out of 68 school days

State DSS (NY) requested court order to State DSS (NY) requested court order to remove and seek commitment due to remove and seek commitment due to medical concerns. medical concerns.

Court Granted order placing custody Court Granted order placing custody w/DSSw/DSS

Source: 15 Misc. 3d 606 (Fam. Ct. NY 2007)

Our Case StudyOur Case Study

History:History:Appx

Date(s)Residence

AppxAge

AppxWeight

Oct 2002 Parents 8.8 237

Nov 2003 Consent

Removal9.9 261

April 2004Returned to

Parents10.9 255

Oct 2004 Removal 11.7 256

Nov 2004Started @

Geisinger12.1 238

Mar 2006Instant

Violation12.1 263

May 2006 With Parents 12.3 266

OK135S070

A Public Health Crisis?A Public Health Crisis?

End ResultsEnd Results

What is the standard for a child What is the standard for a child welfare referral for an obese child? welfare referral for an obese child?

When do you make the referral?When do you make the referral? Does the potential benefit outweigh Does the potential benefit outweigh

removing a child from her home? removing a child from her home?

ReferencesReferences

Murtagh, Lindsey, Murtagh, Lindsey, Judicial Interventions for Judicial Interventions for Morbidly Obese ChildrenMorbidly Obese Children, , 35 35 Journal of Journal of Law, Medicine & EthicsLaw, Medicine & Ethics 497 (Fall 2007) 497 (Fall 2007)

Patel, D., Patel, D., Supersized Kids: Using the Law Supersized Kids: Using the Law to Combat Morbid Obesity in Childrento Combat Morbid Obesity in Children, , Family Ct. Rev. Family Ct. Rev. 43 (2005)43 (2005)

S. Arani, Case Comment, S. Arani, Case Comment, State State Intervention in Cases of Obesity Related Intervention in Cases of Obesity Related Medical NeglectMedical Neglect, 82 , 82 Boston Univ. L. Rev.Boston Univ. L. Rev. 875 (2002)875 (2002)

Documents

Judicial Intervention For Morbidly Obese Children: An Interesting Case Interesting Case Presentation Saint Francis Hospital Dept. of Pediatrics Jay E