A Framework for Understanding Home Environment, Stress Physiology, BMI, and Weight-Related Behaviors Among Preschool Children in the Child Welfare System

Background and Purpose: Children who enter child welfare (CW) have higher overweight/obesity (hereafter obesity) rates than national population estimates whether they are placed in foster care or remain in their home of origin. One of the goals of CW is to improve well-being, yet very little is known about how CW involvement affects childhood obesity, especially in preschool children when eating and activity patterns begin to form. The home environment impacts children’s weight-related behavior, such as eating, physical activity and screen time. For obese children with no CW involvement, interventions that involve parents and modify the home environment promote greater sustained weight loss than school- or community-based interventions. Yet, we do not know what characteristics of the home environment, caregiver, or child explain changes in weight-related behavior in CW-involved children. The purpose of this study was to develop a CW-relevant theoretical framework for understanding obesity risk in CW-involved young children.

Methods: Individual interviews were conducted with 11 CW experts: six case workers and two health services social work supervisors in the Los Angeles child welfare department, and three medical directors of pediatric clinics exclusively serving children in CW to explore and identify how CW involvement affects childhood obesity. Narrative analysis was conducted to identify themes from the interviews to inform selection of a context-sensitive theoretical model of how home environment, caregiver behaviors, and stress interact to affect weight and obesogenic behaviors of children in CW.  

Results: Themes included: (1) pervasive presence and role of stress in the lives of CW-involved children and caregivers; (2) whole systems view of interlocking and transient influences –including caregivers and residential placements - that can increase children’s vulnerability to poor eating behaviors and less physical activity; (3) difficulty with stress management, self-regulation, and coping strategies among young children. A biologically informed theoretical framework for understanding obesity risk in CW was developed by adding a stress psychophysiological component to ecological systems theory (EST). EST describes how family and other environmental factors contribute to children’s weight and health, and how health is affected by the child’s and caregiver’s stress level. The respondents concluded that caregiver stress negatively affects both caregiver lifestyle behaviors and their home environments. The respondents noted that the toxic stress framework,   as identified in the adverse childhood experiences literature, suggests that adversity may activate stress response systems and have detrimental consequences on health, including obesity.

Conclusions and Implications: This biologically informed ecological framework serves as a rich blueprint for investigating and reducing obesity risk among children in the CW system. It focuses social work attention on interlocking health behaviors of caregiver and children, physiological stress processes, leveraging the home environment for health promotion, and the impact of residential changes on stress, health behaviors, and obesity. Research is needed to identify CW-relevant risk and protective factors for healthy lifestyle habits to inform future customized, home-based obesity interventions for CW-involved children, one of the most medically vulnerable populations in the U.S.