As a school-based physical therapist, this issue comes up for me every year. Children are referred for physical therapy (and occupational therapy) evaluations because they are obese. Every year, I wrestle with my clinical decision making regarding these children.

The CDC posts some alarming statistics about childhood obesity:

  • The prevalence of childhood obesity has more than doubled in the past 30 years
  • In 2012, more than ½ of children and adolescents were overweight or obese
  • 70% of obese children (age 5-17) have at least one risk factor for cardiovascular disease

Children who are obese are at high risk for the following medical conditions: pre-diabetes, cardiovascular disease, and orthopedic or joint problems. Additionally, obese children are at high risk for depression and social difficulties.

In school, we see these children as having difficulty participating in P.E. class and recess with their peers. Getting up and down from the floor can be difficult. Self-care, like shoe tying, can be challenging. Additionally, personal hygiene is often difficult. And this sounds like a silly point, but many obese children have trouble with properly fitting clothing, often leaving either stomachs or rear ends exposed.

Schools are doing their part by reforming school lunches (at the government’s doing). P.E. teachers are encouraging participation in before and after-school running clubs. Posters about healthy eating line the school and cafeteria walls. Schools are trying.

I’ve been documenting Body Mass Index (BMI) in IEP’s for students in which weight may be acting as a barrier to education. This can be a controversial practice. My purpose in doing this is to have data points in which to track a student’s progression. A child who has a BMI above the 99th percentile and then drops to the 95th percentile at the following review has shown significant improvement, even if the improvement is not apparent visually. Also, for children with whom weight management is an issue, I try to take measurements at the beginning of the school year, midway through, and right before summer vacation. It does become a delicate balance when taking these measurements and reporting on them to be very mindful of the child’s self-esteem. 

In the past, some parents have been hotlined (Child Protective Services has been contacted) because of a child’s obesity and the resultant physical concerns. This is not common practice, and there has been little follow through when it was done.

However, I still struggle with the idea of pulling a child out of academic time to exercise. Firstly, it is not skilled physical therapy (or occupational therapy). Much of the time the issue is not that a child cannot perform a skill (i.e. shoe tying), but that they cannot perform it on their body. Secondly, will one session a week make a difference? Can we justify more therapy because of a lifestyle?

I often feel helpless in these cases. The teachers want PT and OT for these students. Some parents are insistent, while others are not. The meetings are usually uncomfortable.

So, as clinicians in the school environment, how are we handling this epidemic? Are you keeping these children on your caseload?


~Kathryn Biel, PT, DPT


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  1. Marcy says:

    I agree a difficult issue for all of us. I do not believe that we will make a difference with once a week because it needs to start at home which is often another difficult obstacle. I also agree that this is not a skilled service either. I like that idea of the BMI reporting. I have had only one encounter with this situation and it was inherited from another district. Thank you for sharing.

  2. Heather Cook says:

    This is a problem that I hold close to my heart. I feel so bad for these young children who are starting out with so many strikes against them at such a young age. Unfortunately I do not keep them on my caseload if they dont have a significant gross motor delay to go along with it. But that breaks my heart and has prompted me to start my own side business in hopes of targeting these children (and their families) after school. Thanks for bringing our concerns to the surface.
    Heather, PT

  3. Amy says:

    I’ve only had 2 issues of this directly and both children had prader willi (underlying low tone) so I justified seeing that way. Both children’s endurance was terrible so even walking from point a to b was slow and difficult. Thankfully parents sought medicall help but I did see them bc of GM skill performance interfered with PE & transitions. It is a difficult place to be put in. I always struggle with children who are functional yet have delayed GM skill performance in the school environment (to serve or not to serve… As I am in a rural area and know if I don’t help, no one will). In these situations, I did see the child once per week, educated the sped teachers in activities and developed a home program for the parent to do for exercise. Goal was for improving timely independent access to school as well as performance/ participation in PE ( both children tended to sit out versus participate in PE or playground).These children had underlying muscle weakness and endurance and with therapy they did improve…. Now I am at the point where I feel I can do nothing else to help, and the limitations they face now are mostly to wieght, so I am looking to discharge now after 2 years of school PT. I feel I have made some difference but it now has to be handed over to parents, etc.

  4. Lisa Piccolo says:

    I think as PT’s in school it is important to teach our children about healthy snacks and to provide information to the families, for example provide home exercises programs that our student and parents can follow together. It would be ideal if we can be part of or create a wellness committee. This committee could set up health fairs, recess games, and walking programs. I think it has to be a team effort.

  5. Alisha Tenbus says:

    I too have been faced with the same concerns. I have justified physical therapy services due to the fact that I find that the children are unable to keep up with their peers in physical education class, during social time on the playground, unable to maintain their balance due to difficulty maintaining center of mass of their body, unable to ascend and descend stairs at a pace equal to their peers, are unable to walk at an equal pace to their peers, and are unable to perform certain ADLs such as tying their shoes, changing their clothes in the allotted time, or wiping themselves after toileting. I educate the children about healthy choices and will walk through the cafeteria line with them asking which item is a better choice than another. I also try to speak to the parents and point them toward the FDA Choose My Plate website ( ). If they ask for more information, I provide them with a list of nutritionists in the area. It is a very difficult subject, however I have recently had a student with severe cardiac issues due to their obesity and they were taken to the hospital via ambulance due to the concerns, so I do feel that we have to be diligent with these students. Thank you for letting me know that I am not alone in this struggle. I like the BMI idea also.

  6. Margaret Rogers says:

    I keep children if their obesity or low fitness keeps the child from climbing on the school bus for example, as then the district was sending a Van for a child who could not ascend the lage step. I do try to educate children and families and work with district PE teachers on emphasizing fitness and offering low or no cost before and after school fitness programs. I have kept children as consults and provided pedometers to monitor activity level and encourage more steps each week with prizes like a school labeled cinch sac from the PTA.
    I do find the monthly consult works and involves the classroom and the PE teacher. Providing research demonstrating tha more active children do better academically may help this cause as well and perhaps lead to more exercise breaks throughout the school day.

  7. bernadette girasek says:

    I agree with the idea that PT is justified if children can not access the school building, or their endurance makes it difficult for them to stand for any period of time. I would like to learn more about the nuts and bolts of a before/after school fitness program. I know the PE instructor in my building would be on board in working with me. I wonder if anyone has started one of these up and can point the rest of us in the right direction in terms of process.

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