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2000 Jordan Institute
for Families

Vol. 2, No. 2
April 1997

Neglect and Failure to Thrive

The girl lying in the crib has thin arms and legs and wispy, dull hair. She looks weak, underfed. The child's cries sound hungry to you, but her mother makes no move to feed or comfort her. As you explain that her daughter needs to be examined by a physician, you wonder: is failure to thrive always caused by neglect?

This article will explore the relationship between failure to thrive and neglect, outline the characteristics of high risk groups, and discuss successful intervention strategies.

The Condition

In the medical profession, the term failure to thrive (FTT) is used to diagnose children, primarily infants, who are underweight and malnourished. Doctors compare the infant's weight and height and assess how that fits to standard weight/height charts.

A child is said to be suffering from failure to thrive when a doctor or medical professional finds the child's 1) weight for his or her height is below the 5th percentile of the population on a standard weight/height curve; 2) actual weight is 20% or more below the ideal weight for height; 3) weight gain is significantly slower than normal; 4) triceps skinfold thickness (a measurement of the total body fat) is below the 15th percentile for the population (Schmitt & Mauro, 1989). (See "Traits Associated with Failure to Thrive".)

Despite the scientific criteria doctors use, failure to thrive is difficult to detect—it is often misdiagnosed for people who are short, normally lean, or for infants who have rapid shifts in their height, especially between six and twelve months of age. Usually FTT infants are delivered at full term and are healthy at birth.

Failure to thrive can occur due to organic or nonorganic reasons, although many infants with FTT have both types. Organic failure to thrive results from congential or genetic causes, such as illnesses that affect the respiratory or cardiovascular systems. Nonorganic failure to thrive results from accidental, neglectful, or deliberate action on the caretaker's part. The majority of the nonorganic FTT cases are due to caretaker neglect. Because of this, FTT has long been a concern of child protection workers.

Children at Risk

Children at high risk for nonorganic failure to thrive often come from families in which the mothers have experienced abuse and neglect in their childhood. These mothers often have difficulty relating to others, suffer from chronic depression, and feel overwhelmed and inadequate. They may be uncooperative with social workers or medical staff.

Joseph Fischoff and collegues have conducted a study concluding that mothers of nonorganic FTT infants tend to have character disorders, such as narcissistic personality disorder or dependent personality disorder (Fischoff, Whitten & Pettit, 1971). People with character disorders create challenges for successful intervention because their behaviors are ingrained and difficult to change.

Another study found that mothers of FTT infants tended to blame their babies for failing to gain weight, interpreted the meaning of their babies' crying in negative ways, and had difficulty bonding to their infants because they prioritized their own needs as more important (Haynes, Cutler, Gray, O'Keefe & Kempe, 1983).

Interventions

Early intervention is important with FTT children and their families. Those children who go untreated experience continued growth deficits, mental retardation, deficits in cognitive skills (especially language), and problems in personality development. Treatment of children with failure to thrive involves close monitoring of the child's growth, nutrition, and developmental status over a long period of time. Children sometimes require remedial help such as infant stimulation programs (Hathaway, 1989).

Because of the nature of the symptoms, working with a child who has been diagnosed as failure to thrive requires collaboration with doctors and other medical staff. These professionals are mandated by law to report suspected cases of neglectful nonorganic failure to thrive to their local CPS agency.

In addition to the collaboration requirement in FFT cases, social workers often must decide whether to remove the child from the home. The criteria used to make this decision usually include the severity of the child's condition, the mother's openness to intervention, and whether a plan of safety involving a relative, neighbor, or other interested person can be established.

In some cases, a placement decision may be postponed because the baby requires hospitalization. This type of separation provides an opportunity to assess the mother's ability and willingness to care for the child upon discharge, while ensuring the child's safety during the hospital stay.

If the decision is made to keep the child at home, intensive support of the family often leads to successful recovery. In a paper published in the British Journal of Social Work (1985), Dorota Iwaniec, Martin Herbert, and A.S. McNeish reported on one such intensive in-home program working with FTT infants and their caretakers.

Once the child had been diagnosed, the immediate focus was on attending to the safety and needs of the child and family. The child was enrolled in day care, and routine, ongoing contact in the home was scheduled with health visitors, volunteers, and neighbors to provide moral support and assistance with child care. If the family needed help with housing or other issues of subsistence, that was addressed.

To accomplish specific treatment goals, such as creating calm feeding of the child by the mother and facilitating better relationships between mother and child, researchers used behavioral techniques. These involved role-playing and coaching the desired behaviors (e.g., how to give a child positive cues during mealtimes) and a lot of praise and positive reinforcement.

After the situation stabilized, the intervention focused on long-term needs, such as the mother's relationship to her infant, her depression, and so on. Out of 18 cases, only one child had to be readmitted to the hospital after the intervention had ended more than one year later.

References

Fischoff, J., Whitten, C. F., & Pettit, M. (1971). A psychiatric study of mothers with infants with growth failure secondary to maternal deprivation. Journal of Pediatrics, 79, 209-215.

Hathaway, P. (1989). Failure to thrive: Knowledge for social workers. Health and Social Work, 14(20), 122-126.

Haynes, C., Culter, C., Gray, J., O'Keefe, K., & Kempe, R. (1983). Non-organic failure to thrive: Implications of placement through analysis of videotaped interactions. Child Abuse and Neglect, 7, 321-328.

Iwaniec, D., Herbert, M., & McNeish, A. (1985). Social work and failure-to-thrive children and their families. Part I: Psychosocial factors. British Journal of Social Work, 15, 243-259.

Iwaniec, D., Herbert, M., & McNeish, A. (1985). Social work and failure-to-thrive children and their families. Part II: Behavioural social work intervention. British Journal of Social Work, 15, 375-389.

Schmitt, B., & Mauro, R. (1989). Nonorganic failure to thrive: An outpatient approach. Child Abuse and Neglect, 13, 235-248.

1997 Jordan Institute for Families