CHILDREN WHO FAIL TO THRIVE - PART 2 potx

At that time Frederickdeveloped a rigorous approach to design, measurements, and evaluation.Under Frederick’s aegis, studies were made of the effects of deprivation inchildren, albeit in

to guide Frederick away from occult, magic, and secret paths, and directedhim to more dispassionate scientific experimentation At that time Frederickdeveloped a rigorous approach to design, measurements, and evaluation.Under Frederick’s aegis, studies were made of the effects of deprivation inchildren, albeit in the realms of language acquisition: in order to establishwhat was the original language of mankind, new-born infants were reared byfoster-mothers who suckled and bathed the children, but were not permitted

to speak to them so that they would not learn a language from the mothers No spontaneous acquisition of Hebrew, Greek, Latin, Arabic, or thelanguages of the parents to whom the children were born occurred, for inthose silent domains the subjects of the experiment all died, although it is notrecorded if infection, lack of hygiene, disease, or silence caused their passing.The conclusion was that Frederick II had the will and intellectual wisdom toseek the truth by means of experimentation at a time when passive acceptancewas the established order of the day Frederick is seen as the first scholar toobserve and document the serious effects of deprivation in children, but, likemany other curious and inquisitive observers who followed, he failed to findappropriate answers to the questions he asked There were sundry studies

foster-on the fringes of Renaissance enquiry, but in the seventeenth century SirJohn Harington (1561–1612)4 published his famous book The Englishman’s Doctor Or, The Schools of Salerne (1607), in which he proposed that digestion

was encouraged by pleasurable emotions but inhibited by stressful ones Herecommended ‘three Doctors’ (figuratively speaking of course) to increase anawareness and to suggest what to eat, how much to consume, when to eat,and under what conditions to fully benefit from the taken nutrition He statedthat the quality and amount of food we eat (proper diet) will be beneficial if

we consume it in an atmosphere which is relaxed, calm and happy As he putit:

Use three Physicians still, First Doctor Quiet, next Doctor Merryman, and DoctorDiet

Those who work with children who fail to thrive and their families will findthis quotation very apposite, as it clearly emphasises the importance of ade-quate nutrition and the atmospheres that should surround it The quotationindicates that those ‘three wise men’ are often absent from the nutritional lives

of what are often sad, undernourished children, and of parents who may beanxious, frustrated, demoralised, unsuccessfully trying to feed the child, orneglectful and ill informed about the child’s nutritional and nurturing needs.Documentation of child deprivation and its outcome is very scarce and weknow that during the Middle Ages children were portrayed as adults in smallbodies (Ari`es, 1973) The artist William Hogarth (1697–1764) pictured many

4D.N.B (1917), viii, 1269–72.

aspects of child abuse and deprivation in his widely disseminated engravings,such as ‘Gin Lane’ (1751): his work portrayed cruelty, neglect, and abuse

of all kinds This included nutritional starvation as deprivation-dwarfismsyndrome by showing a child eating garbage, M ¨unchausen Syndrome byProxy, overt abuse, and acute neglect of children’s nutritional, emotional,and physical needs Hogarth tried to draw public attention to the plight ofchildren by depicting different accidents which he observed and which had

an enormous effect on him In 1738 he produced an engraving entitled ‘TheFour Times of Day’ The etching entitled ‘Noon’ portrays a boy carrying a dish

of food, but he has dropped it, spilling the contents In his distress the boy,who knows he is going to be severely punished for it, does not even noticethe ragged girl helping herself to the food on the ground

Institutions for the care of ‘foundlings’ (children, usually illegitimate, whowere abandoned) have a long history There were ‘foundling hospitals’ innumerous European cities, and these have been documented As early as theseventh and eighth centuries there were such establishments in Trier on theMosel (Augusta Treverorum, the oldest town in Germany), Milan, and Mont-pellier (to name but three such), and in the fourteenth century a famousfoundling hospital was created in Venice Paris and Lyons acquired importantfoundling hospitals in the seventeenth century, and from 1704 to 1740 Antonio

Vivaldi (c.1675–1741) was director of the Conservatorio dell’ Ospedale della

Piet`a, one of four celebrated Venetian music-schools for orphaned or gitimate girls (or girls whose parents were unable to support them) TheseState-supported schools provided very high standards of education, and theOspedale della Piet`a’s musical performances were much appreciated andjustly renowned (Blom, 1966)

ille-Indeed, interest in disadvantaged children accelerated during the teenth century, a time when rational enquiry of all kinds proceeded apace.One of the best-known foundling hospitals was that established by Captain

eigh-Thomas Coram (c.1668–1751), shipwright, seafarer, trader, colonist (he was

involved in both Georgia and Nova Scotia), and philanthropist.5Shocked bythe common sight of infants exposed and dying in the streets of London, heagitated for the creation of a foundling hospital, and laboured for 17 years

to that end A Charter was obtained, considerable sums subscribed, and thefirst meeting of the guardians was held in 1739 Some houses were acquired

at Hatton Garden, and the first children were admitted in 1741 Eventually, alarger parcel of land was purchased north of Lamb’s Conduit Street, and build-ings were erected (1742–52, demolished 1928) under the direction of James

Horne (d.1756) to designs by Theodore Jacobsen (d.1772) The first children

were removed from Hatton Garden and settled there in 1745

Huge interest was excited by the undertaking, and support was given bynumerous individuals, including Hogarth, who presented his fine portrait of

5D.N.B (1917), iv, 1119–20.

Coram to that hospital in 1740 Georg Friederich H¨andel (1685–1759) gaveconcerts there between 1749 and 1750, and composed the Foundling Hospi-

tal Anthem, Blessed are they that consider the poor (H¨andel-Gesellschaft, vol 36,

1749), especially for the benefit of the charity (Arnold, 2001; Blom, 1966)

At first, the London Foundling Hospital6 admitted any child under

2 months of age who was free from certain specified diseases, without tion or any attempt to identify its parentage A basket was suspended outsidethe entrance-gate in which unwanted infants were deposited, and a bell rung

ques-to inform staff of new arrivals So great was demand that a system of ballotingfor admission had to be introduced, as fights had occurred outside the gatesamong those mothers wishing to get rid of their unwanted babies Grantswere made by Parliament from 1756, on condition that all children orphanedwere admitted, and in 1757 branch-hospitals had to be opened at Ackworth,Shrewsbury, Westerham, Aylesbury, and Barnet to cope with the 3,727 chil-dren for whom admission was sought This general admission was soon found

to be a mistake, for of the 14,934 children received during the three years itwas in force, no fewer than 10,389 died Parents even brought dying chil-dren in order to have them buried at the expense of the hospital, and personswere paid by parents to bring infants from all over the country to the LondonHospital, but few of those children, through brutality or criminal negligence,ever even reached ‘Coram’s Fields’ alive So abused was the system that Stategrants ceased entirely in 1771, and from then onwards the foundation had todepend on private philanthropy for its funds, and admission was changed

to a process of selection Eventually, a child could only be admitted upon thepersonal application of the mother, and the children of married women orwidows were not received No application was entertained before the birth,nor after a child reached 12 months

The Coram Foundation was among the first to recognise that there wereadvantages in keeping mother and child together for at least the first year,for infant mortality rates could thereby be greatly reduced The herding to-gether of children in larger institutions was also gradually perceived as risky,not only because of the danger of infection, but because an institutionalisedenvironment, except for very short periods, became recognised as being badfor any child Thus a system of boarding out or fostering was developed.The London Foundling Hospital was a pioneer in boarding out, and by the

middle of the twentieth century all children admitted to what had become

the Thomas Coram Foundation for Children were boarded out

Drawing on the well-documented archives of Coram’s Foundling Hospital,Harry Chapin, in 1915, pointed out the susceptibility of infants to inadequate

caring environments, and their undoubted need for individual care Thus it

began to be recognised at the beginning of the twentieth century that theoutcomes of children deprived of individual care were shocking, in that they

6Encyclopædia Britannica (1959), ix, 559–60.

were poor In some places, such as Romania, the quality of care was found

to be equally poor, even at the end of the second millennium Nutritionaland emotional deprivation of children in Romanian orphanages and the lev-els of suffering to which they were exposed have been well documented,and shocked all who saw the horrific pictures of those children and the en-vironments in which they lived Malnourishment, lack of stimulation, andall-round gross negligence affected their physical, cognitive, emotional, andsocial development (in many cases beyond the probability of repair and help)

In Britain the problem of child abuse was beginning to be recognised when

the Offences Against the Person Act (24 & 25 Vict., c.100) became law in 1861:

it forbade the abandonment and exposure of infants under 2 years of age,

but this enactment was difficult to enforce The Poor Law Amendment Act (31 & 32 Vict., c.122, of 1868) stated that parents would be punished if they

wilfully neglected their children in terms of failing to provide adequate food,clothing, medical aid, or lodgings for those under 14 years of age, wherebythe health of the child was likely to be seriously impaired In spite of this leg-islation, very little in reality happened to protect the children, and very fewparents or carers were prosecuted for cruelty and negligence of their charges.Children were considered as private property, so interference in child-rearing

tended to be avoided However, in 1889 a statute (52 & 53 Vict., c.44) was

passed clearly specifying prevention of cruelty to children; this was seded by a number of similar enactments leading up to the more modern and

super-comprehensive Children Act (8 Edw 7, c.67) of 1908.

Abandoned, rejected, neglected, cruelly treated and orphaned childrenwere cared for in the large orphanages or hospitals The poor outcomes ofinstitutional care were widely acknowledged, and many professionals andresearchers expressed their concerns However, Holt and Fales (1923) statedthat, given the appropriate conditions,

strikingly good health and excellent nutrition can be maintained in childrenobliged to live in institutions

After outlining the hazards and dangers for children being cared for inthe infant ward, Joseph Bremeau (1932) made eight recommendations forprevention, one of which was ‘one nurse for two babies, minimum’

Apart from stressing the nutritional needs of children, doctors increasinglybegan to emphasise the nurturing aspect of daily care and the need for inter-action with adults It began to be recognised that in order to grow healthilyand vigorously and to recover more quickly from illnesses, babies need ap-propriate physical and emotional contact with care-givers, as the absence ofsuch continuing nurturance and physical intimacy can bring about anxietyand fretting in children, disrupting biological functions

Development of awareness for the necessity of emotional care was welldescribed by Montagu (1978) In his chapter on ‘Tender Loving Care’ he

described high mortality rates in institutions, and related an interesting dote In a German hospital before the 1939–45 war, a visiting American doctor,while being shown over the wards in one of the hospitals, noticed an ancienthag-like woman who was carrying a very undernourished infant The doctorenquired of the director the identity of the old woman and was told that shewas ‘Old Anna’: when the staff at the hospital had done everything medicallythey could do for a baby, and it still failed to thrive, they handed it over to ‘OldAnna’, who succeeded in remedying matters every time She fed the child,encouraged it to eat, was patient, held it gently, talked to it, rocked, givingtender attention plus the close physical contact which every baby needs: it

anec-is small wonder that babies passed to her, who had been near death’s door,began to thrive due to the increased intake of food and the manner in whichshe fed and looked after them

SOCIO- AND PSYCHO-GENESIS

The hypothesis of a psychological aetiology for failure to thrive has its roots

in the extensive literature on the effects of institutionalisation, tion, and maternal deprivation on infants During the 1940s studies began

hospitalisa-to emerge postulating that emotional deprivation per se could affect

phy-sical growth, and many claimed that deprivation in infancy would lead toirreversible impairment of psychosocial functioning in later life Some of thebest accounts of growth failure at the time were those of Spitz (1945), Talbot

et al (1947), Bakwin (1949), and Widdowson (1951) The ‘disorder of

hospital-ism’ (as Spitz termed it) occurred in institutionalised children in the first fiveyears of life, and the major manifestation involved emotional disturbance,failure to gain weight, and developmental retardation resulting in poor per-formance during tests Spitz compared a group of infants cared for by theirmothers with a group raised in virtual isolation from other infants and adults.Spitz stated that physical illnesses, including infections, are contracted morefrequently by infants deprived of environmental stimulation and maternalcare than those not so deprived The failure-to-thrive syndrome, according

to Spitz, is a direct result of inadequate nurturance: indeed he actually umented long-term intellectual deficit in the survivors of the non-nurturedgroup Of the deprived group, 37% had died by 2 years of age, comparedwith none in the adequately mothered group Spitz stated that a condition

doc-of anaclitic depression manifested itself in severe developmental retardation,extreme friendliness to any persons, anxious avoidance of inanimate objects,anxiety expressed by blood-curdling screams, bizarre stereotyped motor pat-terns resembling catatonia, failure to thrive, insomnia, and sadness It should

be noted that Spitz’s work has been severely criticised for methodologicaland other weaknesses, and it would be inappropriate to link failure to thrive(as we observe and know it now) to the cases of children studied by Spitz A

comparison of the effects of institutionalised rearing, as described by Spitz,with conditions in Romanian orphanages (where children were incarcerated

in badly run, impoverished, and ill-informed institutions rather than by ents in their natural homes) would be more appropriate Nevertheless, thesestudies proved (with the addition of Bowlby’s work) to be significant in aheuristic sense, and have been important catalysts in generating research andinforming policy and practice

par-CAUSAL MECHANISMS

The association between maternal deprivation and failure to thrive has ledsome investigators to hypothesise the existence of a physiological pathwaywhereby emotional deprivation affects the neuro-endocrine system regulat-ing growth

Several studies were done to test growth-hormone efficiency The nism in dwarfism was studied extensively in attempts to answer the question

mecha-‘what factors play a role in growth-hormone arrest and what happens andunder what circumstances are they switched on again?’ These studies con-centrated on various forms of growth failure, but particularly on dwarfismwithout organic cause Dwarf children were defined by Patton and Gardner(1962) as being below the 3rd percentile in height, with weight below thatexpected for the height (though exceptionally that weight may be appropri-ate for the height), and the child might appear well nourished However,such appearances may be deceptive because neither weight nor height is nor-mal for the chronological age Patton and Gardner postulated that emotionaldisturbances might have direct effects on intermediary metabolism so as tointerfere with the anabolic processes The production and release of severalanterior pituitary hormones are influenced by hypothalamic centres, whichare, in turn, recipients of pathways from higher neural centres, particularlythe limbic cortex (also thought to be the focus of emotional feelings and be-haviour) These authors, on the basis of six very thoroughly studied children,favoured a theory of emotional influence on growth with secondary hormonalinsufficiencies as the main cause of the dwarfism

Apley et al (1971) made penetrating enquiries based on paediatric,

psychi-atric, and social-work team-work information to discover the truth about thefood-intake of individuals with dwarfism syndrome in Bristol Their exhaus-tive clinical, biochemical, and endocrine tests on all the children ruled out theoperation of pathological causes in the stunting of growth, and, by inference,they pointed to under-feeding as the cause

In 1947 Nathan Talbot and his co-workers reported on the concept ofdwarfism in healthy children and its possible relationship to emotional, nutri-tional, and endocrine disturbances Their work foreshadowed much of what

is now known about these children They found that children studied were

physically healthy, were small with a height-age less than 80% of actual age,were underweight for height, had low caloric intake, were anorexic secondary

to emotional disturbance, had no significant history of short stature, and hadscanty subcutaneous tissue They were the first to point to ‘chronic grief’ asone of the causes of dwarfism They studied over one hundred individualswith dwarfism syndrome between 21/2and 15 years of age, but were not able

to find any organic cause for the stunting in growth The nutritional history ofthese children clearly indicated that there were feeding problems for a majorpart of their lives (and in some cases since birth): the authors postulated thatonce a child became undersized, it continued with basically reduced proteinand calorific requirements, and, the pituitary function having become adap-tively reduced, it failed to function normally when the diet improved Somechildren, therefore, remained small though apparently well nourished Talbotand his colleagues treated them with pituitary hormones and discovered thatsome of these children, both the well-nourished and thin ones, were capable

of good growth over many months thereafter

However, they discovered through psychiatric and social studies that thebackgrounds of these children were grossly problematic, and listed the fol-lowing features in 24 of them:

r34% rejection;

r14% poverty;

r14% mental deficiency;

r19% chronic grief;

r14% maternal delinquency; and

rbreakdown in family and marital relationship in 14% of cases

No abnormality was found in only 5% of cases In seven well-nourishedchildren no abnormality was found in three cases, maternal delinquency orbreakdown in three, and rejection in one Four of these children with disturbedmaternal relationships were stunted in growth, but on the surface appearedwell nourished The outcomes suggested that the intake of food was not thewhole answer to the cause of the dwarfism, and led other researchers topursue the hormone studies

In 1949 Bakwin concluded that failure to thrive in institutions is the sult of emotional deprivation, and that emotional reactions arise principally

re-in response to sensory stimuli He believed that children who are talised should receive attention and affection, and should often be held inthe arms of adults He proposed that the mother should be at the baby’s bed-side most of the time and that preoccupation with infection was ill founded

hospi-He described the appearance and psychological expression in the followingways:

Appearance Psychological expression

Listlessness No interest in food, accepted passively

Absence of sucking habits Unresponsiveness

No interest in surroundings Insomnia

Bakwin associated poor growth development and psychological tion with emotional deprivation and absence of maternal care while in hospi-tal He questioned the aetiology as being directly linked to nutrition, infection,and the psychological make-up of a child

presenta-Widdowson (1951) reported in The Lancet the effects of psychosocial

de-privation on children’s physical growth She replicated Spitz’s findings thatadequate calorific provision in an unfavourable psychological environment(due to harsh and unsympathetic handling) may seriously curtail growth-rates Just after the Second World War, Widdowson studied children in twoGerman orphanages where she was stationed as a British Army medical of-ficer Each orphanage accommodated around 50 boys and girls of a wideage range between 4 and 14 years A dietary supplement, which was expected

to produce faster weight gain, was introduced as an experiment in one phanage, using the other as a control Contrary to expectation, it was thecontrol group which gained weight and grew a little faster during the exper-imental period of six months Afterwards it was discovered that the matrons

or-of the two orphanages had swapped over at about the time or-of the start or-of thedietary supplement The matron in charge of the experimental group (whohad transferred to the control group) had been a kindly, caring, and warmperson, but the matron originally in charge of the control group (who hadtransferred to the experimental group) was harsh, a hard disciplinarian whotended to harass the children at meal-times Such harsh behaviour could wellhave caused some achlorhydria and also anorexia (though it is unlikely thatthe children would have been allowed to leave anything on their plates).One may speculate that the dietary supplement was wasted This studysuggests that nutritional intake (to be beneficial) has to take place in relative

calmness and in an anxiety-free state, and that non-nutritional emotional tors play an important role in digestion and absorption Indeed, one of theindices of basic trust and security in an infant (in Erikson’s sense) is stablefeeding behaviour, and eating (to be beneficial nutritionally and enjoyable)requires conditions conducive to a relatively benign and calm state of psy-chosomatic harmony But without adequate consumption of food a child willnot put on weight, so feeding it quantities needed for its age is the first re-quirement The second requirement is calm and friendly interaction duringfeeding/eating times, and the third is sensitivity and awareness of a child’spersonal characteristics, i.e temperament, and of some feeding difficulties(such as oral-motor problems or other illnesses) which make eating uncom-fortable or painful.

fac-In her wise paper (ibid.), Widdowson’s biblical quotation (Better is a dinner

of herbs where love is, than a stalled ox and hatred therewith [Proverbs, xv, 17]) is

very pertinent—all of us can identify with it to some extent We enjoy foodmore and are more eager to eat when we are happy and in the company ofpeople we like than when we are stressed, anxious, and miserable

MATERNAL PATHOLOGY AND GROWTH-FAILURE

In the late 1950s and 1960s, studies of growth failure and developmentaldelays, similar to those found among institutionalised children, were repli-cated on infants and young children living at home Studies of such childrenand their families have shown that the most commonly identified precursors

to these growth problems are emotional disturbance and environmentaldeprivation—with the wide range of psychosocial disorganisation thatthese concepts imply Deprivation often involves rejection, isolation fromsocial contact, and neglect These associations with poor growth have beendelineated in the context of maternal personality problems, stemming fromthe mother’s own early background, family dysfunction, immaturity, socialisolation, and mental-health problems Other psychological difficulties havebeen found to stem from the manner in which mothers nurture their smallinfants The prevailing view was that socio-emotional deprivation could bethe cause of some cases of short stature, and that the most likely aetiologywas deprivation or inadequate, disturbed mothering in general (Coleman &Provence, 1957; Patton & Gardner, 1962), and that failure to thrive was occa-sioned either through diminished intestinal absorption, faulty conservation of

nutrients, or possible abnormality of endocrine function (Leonard et al., 1966).

POINTING THE FINGER AT THE MOTHER

In cases considered with the concept of the Battered Child Syndrome duced by Henry Kempe and his colleagues in 1962, theorists, researchers, and

intro-clinicians have explored the causes of child abuse and neglect, including ure to thrive For a considerable time the medical–psychiatric model of thecausation and treatment was favoured, attributing the blame for its occur-rence to the pathological personality structure of the mother and her history

fail-of having herself been abused and neglected as a child Let us look at a fewstudies conducted at the time and their preoccupation with maternal failings.Coleman and Provence (1957) presented detailed reports of two infantsfrom middle-class families in whom they postulated retardation of bothgrowth and development resulting from insufficient stimulation from themother and insufficient maternal care In the first case the child was difficult

to feed and presented as generally passive and difficult to enjoy When theinfant was 7 months old the mother was pregnant again During that time,the mother’s father committed suicide The mother showed grief, depression,and anger over a prolonged period and further neglected the child

In the second case the mother was isolated and emotionally detached fromher infant: she stopped breast-feeding on the fourth day after birth becauseshe said she was afraid she would smother the child, and spanked the infantbecause its crying drove her wild She alternated between feelings of depres-sion and helplessness over the baby’s poor development The baby was notplanned or wanted and the mother resented breaking her career The authorsdid not make any distinction between these two infants and mothers It isclear, however, that both babies were undernourished and failed to thrive:one presumably because of feeding difficulties and maternal grief; and thesecond because of rejection and inadequate provision of food

Fischhoff et al (1971) conducted a study of 12 mothers of 3- to 24-month-old

infants Their findings were based on two interviews with the mothers, briefcontacts on the wards, social-work reports, unstructured interviews with thefathers, and reported observations by paediatricians and nurses They con-cluded that 10 out of 12 mothers presented enough behavioural signs to war-rant diagnoses of character disorder These women (according to the authors)presented a constellation of psychological failures conducive to inadequatemothering, including:

rlimited abilities to perceive accurately the environment, their own needs,

or those of their children;

rlimitations of adaptability to changes in their lives;

radverse affective states;

rdefective object-relationships; and

rlimited capacity for concern

Since character disorders (in the view of many) are untreatable, they gest that some of these failure-to-thrive children may be better off in foster-homes Although mothers in their small sample were found to presentcharacter disorders, it would be wrong to say that all mothers or the majority

sug-of mothers whose children fail to thrive have personality disorders Thelabel can also be a facile and meaningless designation, devoid of usefulimplications.

Similar and different signs of psychopathology have been identified amongmothers of failure-to-thrive children Barbero and Shaheen (1967) foundmothers in their sample depressed, angry, helpless, and desperate, and suffer-ing from low self-esteem However, they drew professional attention to thosechildren who might be at risk of being inappropriately diagnosed, notedthat there were some who failed to thrive because of abuse or neglect, andthat such children should be referred to appropriate helping agencies Theypostulated that those mothers lived with significant environmental and psy-chological disruption, such as alcoholism, childhood abuse, family violence,and general family dysfunction

Again, Leonard et al (1966) described similar characteristics found in 13

mothers of infants who failed to thrive: these included tension, anger, anxiety,and depression, but it proved difficult to disentangle cause and effect because,for example, failure to thrive in an infant might have contributed to such states

in the women Mothers in this comprehensive study were poorly motheredthemselves, were sexually traumatised as children, and had experiencedfamily instability The authors found that those mothers were lacking in self-esteem, unable to assess their babies’ needs and their own self-worth realis-tically, and were lonely, isolated, and depressed The authors described thesemothers as severely malfunctioning and disturbed

Spinetta and Rigler (1972) have hypothesised on the basis of their studiesthat the parents of failure-to-thrive children (like parents who have physicallyabused their children) have themselves been physically abused and neglected

in childhood Bullard et al (1967) found from their study of 50 FTT children

that neglect (identified as lack of interest by parents) is the major cause of thatcondition They identified factors contributing to neglect, such as instability oflifestyle, severe marital strife, erratic living habits, alcoholism, a history of en-tanglements with the law, and inability to maintain employment or to providefinancial support for the care of the children The mothers tended to describelack of feelings for their children, and admitted to leaving them unattended orwith strangers for long periods The authors questioned the appropriateness

of using the blanket term ‘maternal deprivation’ when applied to thrive children, feeling it should be used more specifically and should refer

failure-to-to possible inadequacies in feeding, holding, and other care-taking activities

of the mother The proposition emerged at that time that failure to thrive (assecondary to maternal deprivation) was based on evidence that the child hadlittle physical handling by the mother, or no appropriate social contact Suchmothers were said rarely to hold, cuddle, smile at, play with, or communicatewith their children The researchers observed that those mothers might lackpositive feelings for their children, and could be insensitive to and unable

to assess their needs, particularly with regard to hunger These aspects havebeen highlighted by several researchers (Coleman & Provence, 1957; Leonard

et al., 1966; Bullard et al., 1967; Fischhoff et al., 1971) In these studies feeding

was singled out as a time of major conflict between mother and child: none

of them, however, examined or measured how much food was consumed bythe children

In 1967 Powell and his colleagues (Powell et al., 1967) measured

growth-hormone response along with other endocrine studies in 13 children Theydescribed many of the common social circumstances in families of childrenwho failed to thrive (which included divorce, marital difficulties, alcoholism,and extra-marital affairs), and they noted that the fathers spent little timewith the children In addition to their endocrine studies they made inter-esting observations of the children’s behaviour, such as soiling and wetting;stealing food; eating non-food items; eating from garbage cans; gorging andvomiting; wandering around the house at night; playing alone; and havingtemper-tantrums Such children tended to be malnourished, thin, and short,with weight-for-height appearing normal or greater All children in their sam-ple were observed to be short, with weight-ages ranging between 30% and66% of the chronological age The oldest boy, when initially seen, was 111/2

years old, with a height-age of 51/2years: his weight was normal for his height.The head circumferences were −1 to −11% of the average head circumfer-ence for the chronological age and+1 to −9% of the average circumferenceexpected for the actual height All had protuberant abdomens and some haddecreased muscle bulk Many had retarded bone-ages commensurate withtheir height-ages All the children had depressed or infantile nasal bridges,giving a younger naso-orbital configuration than expected for their age.The researchers concluded that aetiology of the growth failure and possiblehypopituitarism was unresolved

In 1969 Whitten and his associates (Whitten et al., 1969) began to

ques-tion some of the concepts of subtle influence of deprivaques-tion or neglect uponmetabolic functioning They postulated that growth-failure occurs because

of under-nutrition, and they presented evidence arising from a study of dren hospitalised because of their failure to thrive: they found that 11 out of

chil-13 children gained weight at an accelerated rate when adequately fed whileliving in a hospital environment where personal care was given to them Inaddition, seven out of seven depressed infants rapidly gained weight in theirown homes when given an adequate diet by their mothers in the presence of

an observer They went further to say that children gained weight when fedthe appropriate amount of food regardless of whether or not they receivedextra stimulation or attention They concluded that maternally deprived in-fants are underweight because of under-eating, which is secondary to notbeing offered adequate food or to not accepting it, and not because of somepsychologically induced defect in absorption or metabolism

The findings of Whitten et al.’s study of 1969 was a turning-point for many

researchers The emphasis was put on the energy intake, rather than onconcentrating exclusively on emotional deprivation and abuse, although bothcould be in operation It was recognised that maternal perceptions and state-ments on how much a child consumed in terms of calories were not alwaysaccurate, and that some children were simply starved MacCarthy and Booth(1970) studied the influence of deprivation on somatic growth, and concludedthat deprivation-dwarfism is caused by malnutrition because of inadequateintake of food They suggested it is likely that these children are not givenenough food by the mother, and that, consequently, because of chronic under-feeding, they become undemanding

The studies conducted in the 1960s and 1970s showed striking ties in clinical observations of personalities and behavioural features of themothers of failure-to-thrive children These observations, however, are some-what questionable because of the absence of contrast or control groups As

similari-we know, clinic-attending patients make for a notoriously biased sample Afurther weakness of much of the work is the absence of evidence on the relia-bility or validity of the procedures used for data collection Most of the studiesthen (as well as now) are based on retrospective data and therefore have to beinterpreted with caution Early studies have been based on observations ofchildren and parents mainly in hospitals or clinics, so observations of inter-actions and quality of care at home, including feeding style and nutritionalintake, were not taken into consideration It is well known that people behavedifferently, present a different picture of themselves, and tell different storieswhen away from their natural habitats Nevertheless, much has been learnedfrom those small, hospital-based studies They were not different in qualityand validity to those of child abuse The mother was seen as all-powerful, aswell as wicked, who was wholly responsible for good and bad in the child’soutcomes The next chapter will deal with more recent studies and the chang-ing philosophy about aetiology and controlling mechanisms of failure tothrive

SUMMARY

Failure to thrive is as old as human history There have always been childrenwho fail to thrive, and, although they were not labelled as such, they weredescribed as ‘sickly’, ‘weak’, or ‘defective’, and their fate, as a rule, was death.This chapter provides glimpses only of child-rearing, care and protection overthe centuries It aims to put into context the development of child welfare andthe long and painful journey to reach current views of a complicated matter.Failure to thrive (as it was coined by Holt in 1897) has gone through variousstages of knowledge-development as well, and these stages have been brieflysummarised above

It was once argued that hospitalised and institutionalised children failed

to thrive because they did not receive maternal nurturing and attention as aresult of separation from their mothers However, when children who failed

to thrive began to be studied in their own homes, they showed the sameoutcomes, and it was assumed that their condition had developed because

of neglect or abuse As will be demonstrated below, neither simplistic viewembraced the full picture

the author (and which will be used throughout this book) is: failure to thrive

in infants and children is failure to develop in terms of weight-gain and growth at the normal speed and amount for their ages as a result of inadequate calorie intake.

Failure to thrive (or under-nutrition during infancy and early childhood)

is a common problem and is usually identified during the first three years

of life When children are undernourished they will fail to gain the quired weight After a while their growth in terms of height also falters

re-On the growth-chart they remain or drop below the 2nd percentile (or thelowest line) of weight or height Most children are diagnosed as failing tothrive when their weight- and height-percentiles are low and remain lowfor two to three months Others are diagnosed when growth drops downacross two or more percentiles, and when there has not been any obvious

reason for this, such as illness or the normal slimming associated with tended mobility and activity-levels during the crawling and walking stages ofdevelopment.

ex-Additionally, genetic growth expectation is considered (e.g the parents’heights and weights), so for a small child who has small parents to be la-belled as failing to thrive, that child would have to be low in weight forheight, or demonstrate poor weight-gain velocity, since weight-for-age wouldnormally be low However, it needs to be remembered that parental heightmight not represent actual genetic potential, as those parents might havefailed to thrive as children, and their growths could possibly have beenstunted

The causes of FTT are often divided into three categories: organic, organic, and combined Organic failure to thrive is thought to result fromillnesses or genetic conditions, whilst non-organic failure to thrive may de-rive from inadequate parenting and from various environmental factors.Combined FTT may have both organic and non-organic origins Whateverthe sources of failure to thrive, it is always associated with under-nutrition,whether that is caused by a disease that blocks or interferes with the absorp-tion of nutrients or by an inadequate food intake in quantity and quality for

non-the child’s age and size (Dykman et al., 2000).

Different terms are used to describe failings in weight and height as stated

by the World Health Organisation (WHO) Expert Committee (1995) Theseare:

1 low height-for-age (called stunting), considered to be an indicator of

long-term malnutrition and poor growth;

2 low weight-for-height (called wasting), a result of recent severe weight loss;

and

3 low weight-for-age (called underweight), found in both stunting or wasting.

As a rule, researchers use the measure of low height-for-age (stunting) as

the selection criterion for growth deficit (Walker et al., 1992; Voss, 1995) It is

generally recognised that stunting is the most widespread indicator of growthdeficiency across the globe, even though weight-for-age is the usual screening

parameter for undernourished children (Reifsnider et al., 2000) Stunting can

be discriminated from failure to thrive (which is a symptom rather than a

diagnosis), because, as a rule, FTT shows low age or height (WHO Expert Committee, 1995)

weight-for-PREVALENCE OF FAILURE TO THRIVE

Although failure to thrive usually occurs early in a child’s life, its effects andconsequences can be observed at the older toddler stage, middle childhood,