Parenting style and developmental status among children with nonorganic failure to thrive

Examined differences in several developmental indices of competence among 102 low-income, inner-city, predominantly African American children with non-organic failure to thrive (NOFTT) and a comparison group of 67 children with adequate growth matched on age, gender, race, and socioeconomic status. Parents were categorized into one of three groups (nurturant, authoritarian, and neglecting) based on observations during feeding. Parents of children with NOFTT were less nurturant and more neglecting than parents of comparison children. Associations between parenting style and children's social-cognitive development were similar across groups. Children of nurturant parents consistently demonstrated better social-cognitive development. Results support the importance of considering heterogeneity among high-risk families and the need to examine the relationships linking parenting style and child development.

Failure to grow: lack of food or lack of love?

One of the most important criteria for good health in childhood is normal growth. Taking regular accurate measurements of length and plotting them on a centile chart is essential to spot early signs of growth disorders. Be alert for a "zig-zag" pattern on the chart: it could indicate psychosocial dwarfism (see opposite). Length is more important than weight for identifying growth disorders. Lack of love, or an adverse emotional or social environment, can cause growth failure even in a child who is eating enough. Such children have a condition called psychosocial dwarfism, which is due to hypopituitarism (too little growth hormone secretion from the pituitary gland). This condition does not respond to growth hormone treatment. Once the child is placed in an alternative environment, eg a good foster home, the hypopituitarism is reversed and rapid "catch-up" growth takes place. It often emerges that such children have been physically, emotionally or sexually abused.

Factitious food allergy and failure to thrive

OBJECTIVE

To examine the relationship between parental beliefs about factitious food allergies and failure to thrive in their children.

RESEARCH DESIGN

Retrospective case review.

SETTING

Tertiary care referral center in Denver, Colo.

SELECTION PROCEDURES

A consecutive sample of more than 700 patients referred for evaluation of food allergies was screened for age; negative results to double-blind, placebo-controlled food challenges; and failure to thrive.

MEASUREMENTS/RESULTS

After identifying two probands, we identified nine additional children with failure to thrive in the context of parents' beliefs in allergic reactions to multiple foods. The results of puncture skin tests conducted for foods suspected of causing allergic reactions were negative for seven (64%) of the 11 children. There were no allergic reactions to open challenges (ie, children, staff, and parents knew which food was being tested). Only two patients reacted during double-blind, placebo-controlled food challenges. One reacted to milk (one of 14 suspected foods) and the other reacted to eggs and milk (two of 15 suspected foods).

CONCLUSIONS

Parental beliefs about food allergies can lead to dietary restrictions severe enough to cause failure to thrive in their children. Because of the wide-spread belief by parents that children are allergic to food, pediatricians are frequently faced with the question of whether to subject children to food restrictions. Their collaboration with unsubstantiated parental beliefs can have long-term, deleterious consequences.

Role of the mother's touch in failure to thrive: a preliminary investigation

OBJECTIVE

This study investigated the hypothesis that specific types of maternal touch that might promote infant growth are reduced in cases of failure to thrive (FTT) and tested reports that maternal physical interaction and physical affection are diminished in FTT.

METHODS

Frequencies of operationally defined maternal touch categories were scored by blinded raters from videotaped mother-child feeding and play interactions of 21 children, aged 9 to 19 months, with FTT and 18 normally growing comparison children. After scoring and statistical analyses were completed, investigators unblinded to group status and clinical data reviewed the videotapes of the dyads with the lowest touch scores.

RESULTS

Mothers of children with FTT provided less matter-of-fact touch in feeding (p = .017) and unintentional touch in play (p = .048) than the comparison group, and there was a trend (p = .082) for them to provide less proprioceptive stimulation in play. Unblinded case reviews indicate that, among children with FTT, extremely infrequent touch signals a marked touch aversion by either the mother or child.

CONCLUSIONS

Types of maternal touch that may promote growth or facilitate feeding are reduced in FTT, due, in extreme cases, to maternal or child touch aversion. Clinicians evaluating FTT should be alert to very infrequent touch in the mother-child interaction and consider whether it may represent a maternal intolerance of physical contact with her infant or a problem with the infant's feeding competence.

Behavioral assessment and treatment of pediatric feeding disorders

Pediatric feeding disorders are estimated to occur in as many as one in every four infants and children, and when serious can require numerous, costly and sustained interventions. For over a decade research has cumulated evidence on the contributions of Behavior Analysis in understanding and remediating some types of pediatric feeding disorders. The systematic use of this body of evidence in conjunction with other approaches (medical, nutrition, occupational therapy, physical therapy, and so forth) is being carried out on an inpatient treatment unit at the Kennedy Krieger Institute. Key aspects are described here, including direct observation behavior assessment, approaches for increasing and decreasing feeding behavior, skill acquisition, transfer of treatment gains, and parent training. The results based on case studies and overall program evaluation indicate that medically complicated, severe feeding disorders can be treated successfully in a few months with a multidisciplinary approach which incorporates behavioral procedures.

Nonorganic failure to thrive: developmental outcomes and psychosocial assessment and intervention issues

Serious growth problems, such as Nonorganic Failure to Thrive (NFTT), place an infant/toddler at significant risk for poor developmental outcomes. Evidently, an NFTT child's malnutrition and subsequent poor growth and development are accentuated by a family context of impoverishment, dysfunctional relationships, inadequate education, and a dearth of developmentally enriching experiences. The purpose of this review is to describe NFTT, to present development outcomes, and to discuss psychosocial assessment and intervention issues relevant to this developmental disability of early childhood. An ideographic approach to case conceptualization, evaluation, and treatment is suggested to achieve successful developmental outcomes and to guide research endeavors.

Case study of a high-risk neonate failing to thrive post-extracorporeal membrane oxygenation and post-necrotizing enterocolitis

Infants discharged from neonatal intensive care units (NICUs) often face a long journey of chronic illness, family stresses, and financial burdens. Health care professionals involved in acute care need to be aware of the far-reaching repercussions of neonatal illness. This report presents a case study of a low-income, single mother from a rural community and her son, a neonatal intensive care unit (NICU) graduate post-extracorporeal membrane oxygenation (ECMO) and post-necrotizing enterocolitis (NEC) discharged with a gastronomy tube (g-tube) and failure to thrive (FTT), from his birth to 10 months of age. Family-focused interventions aimed at improving growth and developmental delays and providing family support will be discussed.

Failure to thrive in elderly people: a conceptual analysis

The concept 'failure to thrive' (FTT) has been in the pediatric and child development/child psychiatry literature for many years. Recently it has appeared in the medical literature in relation to malnutrition, weight loss and depression. This paper draws upon the wider concept as applied to infants and young children, as well as on relevant gerontological literature, to analyse FTT as it relates to elderly people. Attributes, antecedents and consequences are identified. Case studies that illustrate the attributes, some of the attributes, or none of the attributes are provided.

A prospective study of family environments of children hospitalized for nonorganic failure-to-thrive

Family functioning of nonorganic failure-to-thrive (NOFT) infants was compared with that of physically healthy, normally growing infants of similar socioeconomic status shortly after the time of the diagnosis of this condition (average age of 5 months) and again at 4 years of age. Families of NOFT infants demonstrated less adaptive relationships than did comparison-group infants, as measured by the Family Relationships Inventory (FRI) at both time points, but a comparable number of changes in residence and constellation on follow-up. Contrary to prediction, the quality of family relationships at point of diagnosis did not predict subsequent family relationships, residence, or constellation changes in the NOFT sample. However, more adaptive family relationships in the comparison group at study entry predicted fewer residence and constellation changes and more cohesive relationships 3 years later. The impact of significant discontinuities in family functioning and status should be considered in research and in clinical interventions with NOFT children.

Oral feeding treatment of children with chronic food refusal and multiple developmental disabilities

This research concerned the treatment of chronic food refusal in 2 children with multiple developmental disabilities. Therapeutic intervention consisted of a multicomponent treatment package that included the (a) elimination of feeding "demands" that provoked child agitation, (b) incorporation of sensory stimulation as contingent reinforcement, and (c) gradual introduction of the requirements for oral consumption. Each child received treatment during individualized training sessions and, subsequently, under naturalistic mealtime conditions. Consistent oral consumption was achieved rapidly by both children. Results were maintained at follow-up assessments ranging from 4 to 12 months.

'Dyschronia' in a patient with Tourette's syndrome presenting as maternal neglect

We report an unusual and unsuspected cause of maternal neglect in a patient with Tourette's syndrome. An important cause of the behaviour appears to have been a form of dyscalculia characterised by a complete inability to appreciate the passage of time. To our knowledge this is the first case of its kind to be reported.

Psychiatric presentation of Crohn's disease. Diagnostic delay and increased morbidity

Four children presented to child psychiatric clinics with a variety of symptoms. They were all later recognised as having Crohn's disease. There was a significant delay between the onset of symptoms and diagnosis, compared with a control group of patients with Crohn's disease whose presentation was with predominantly gastrointestinal symptoms, which was associated with evidence of increased morbidity. Children with abdominal and psychiatric symptoms occurring in combination need serial assessments of physical status, including height and weight, and measurements of inflammatory and nutritional status.

Conservation-withdrawal reaction in infancy? An underdescribed entity

Conservation-withdrawal is considered a biological non-pathological process subserving survival in circumstances which pose an extreme threat to an infant, child or adult. Although initially described in an infant, is reported frequency in that age group seems sparse. Four infants are described, three of whom presented with weight loss. Despite their mothers' assertions that their breast feeding was adequate, the three infants gained weight rapidly on complementary feeding and became more responsive. Previously they had passively accepted sub-optimal intakes, crying little and sleeping excessively. When their initial crying and objection went unheeded, they seemed to pass into a conservation-withdrawal state, conserving their energies, biologically adapting to their mothers' inability to provide adequate nutrition. These infants did not appear ill and investigations proved normal. With adequate feeding, rapid improvement was observed in their weight gain, activity and responsiveness with normal development. Their mothers' selective denial of their own inadequate breast supply resulted in their inability to perceive their infants appropriately, depriving them of their nutritional needs. Additional factors of emotional deprivation and neglect may have occurred in the fourth infant. The responses of these infants observed during their period of severe stress, may appropriately be characterised by Engel's conservation-withdrawal state.

A legacy of violence in nonorganic failure to thrive

It is often postulated that a mother's past experiences influence her ability to function as a parent. If those past experiences involve her as a victim of abuse, what lies ahead for her offspring? We studied 59 mothers of children referred for nonorganic failure to thrive (NOFTT) to the University of Colorado Health Sciences Center and compared their abuse history with a group of 131 mothers of children with normal growth. The mothers of NOFTT children were younger but of the same socioeconomic groups as the comparison mothers. Mothers of NOFTT children had a significantly higher history of abuse when compared to the comparison group p < 0.001. A surprising 80% of mothers of NOFTT children reported they were victims of abuse. We alert clinicians to the likelihood that mothers of children with NOFTT may be victims of abuse and that successful treatment of the child depends upon treatment of the mother-child dyad.

Antecedent manipulation in the treatment of primary solid food refusal

A 4-year-old with primary solid food refusal was treated with systematic fading of utensil type and food texture, using a multiple probe design across food groups. The subject was a multi-handicapped boy hospitalized for feeding problems, self-injurious behaviors, and sleep cycle reversal. At admission, the subject received all nutrition in the form of a liquid nutritional supplement through regular bottle feedings every half hour. Craniofacial anomalies and past multiple facial surgeries precluded the use of a physical prompting procedure. During the first treatment phase, pureed foods were presented with a preexisting stimulus (a regular baby bottle). Accepted presentations were reinforced with music delivered through headphones. All other behaviors received neutral consequences. In the second treatment phase, undiluted pureed foods were presented in bottles, which allowed experimenter control of the size of the bolus entering the mouth. Consequences were identical to those in Treatment 1. Next, spoon-feedings were introduced with the same consequences in place. Reinforcement with a newly acquired preferred food was initiated and faded to a variable ratio three (VR3) schedule. This fading procedure was effective in teaching this young multihandicapped child to consume a nutritionally balanced diet of pureed foods with an average acceptance of 94% and a concomitant decrease in inappropriate mealtime behaviors.

Substance abuse in adolescent mothers: strategies for diagnosis, treatment and prevention

Adolescent drug addiction and alcohol abuse are on the rise in this country. Teenagers of all races, socioeconomic groups and both genders have become avid experimenters with a full spectrum of substances, including alcohol, marijuana, stimulants, cocaine and hallucinogens. A diagnosis of addiction requires familiarity with the normative trends of adolescent behavior, as well as deviations from these trends. Moreover, an adolescent mother with a drug addiction problem confronts the additional burden of fostering adaptive developmental patterns in her infant. Treatment techniques such as previewing, which empowers through the representation and enactment of future outcomes, have helped addicted teenage mothers relinquish drug use and adopt more mature caregiving behaviors.

Eating disorder in a 6-year-old Asian girl with ethyl malonic adipic aciduria

Accurate data are not available for the prevalence of eating disorders amongst the Asian population in Britain. Only a handful of cases have been reported in the literature [Bhadrinath (1990). British Journal of Psychiatry, 156, 565-568.] suggested that it is an uncommon phenomenon despite Dolan's recent finding [Dolan, Lacey, & Evans (1990). British Journal of Psychiatry, 157, 523-528.] that there were elevated Eating Attitudes Test (EAT) scores in a sample of young Asian adults compared with Caucasians. We report a case of an Asian girl with a rare inborn error of metabolism and an eating disorder.

Cognitive-behavioral treatment of health-impairing food phobias in children

Three cases reports describe assessment and treatment of three boys (ages 6 to 8 years) hospitalized because of weight loss and malnutrition, caused by severe dietary restriction and/or refusal to eat solid food. Psychological, behavioral, and medical assessments indicated that the boys were of average intelligence, without other significant psychological or medical disorders. Their eating disturbances were conceptualized as phobic disorders maintained by family factors reinforcing the children's avoidant behaviors. Cognitive-behavioral treatment consisted of an individualized combination of contingency management, shaping, desensitization, relaxation training, education, and cognitive restructuring. Generalization and maintenance were promoted by training parents to implement treatment at home before discharge. Treatment positively affected overall caloric intake, weight gain, number of solid foods accepted, and incidence of emesis.

Personality development, problem solving, and behavior problems among preschool children with early histories of nonorganic failure-to-thrive: a controlled study

Using a prospective study design, 48 preschool children with early histories of nonorganic failure-to-thrive (NOFT) and 47 physically healthy children of comparable age, sex, birth order, and family demographics were compared on measures of problem solving and personality development (ego control and ego resiliency). In responding to structured measures, NOFT children demonstrated deficits in behavioral organization, ego control, and ego resiliency compared with controls. Parents also identified higher levels of behavioral symptoms in children with early histories of NOFT compared with controls. However, home observational measures of ego control and ego resiliency did not differentiate the two groups. Deficiencies in problem solving and personality development and increased levels of behavioral symptoms in preschool children with early histories of NOFT may affect their future socioemotional development and learning.

Failure to thrive: a parent-infant interaction perspective

The purpose of this study was to prospectively study inpatients admitted for failure to thrive during their first year of life. Twelve infants with failure to thrive were studied and compared with 17 healthy controls. Mothers and infants with nonorganic failure to thrive scored lower on the Nursing Child Assessment Feeding Scale, reported more change in their lives, and less social support. The need for further research is discussed and suggestions for beginning level interventions are made.

Psychosocial concomitants of children's feeding disorders

Compared behavior problems, child developmental skills, home environment, and parent emotional distress for 50 families of children aged 11-70 months with differing etiologies of feeding disorders (FD). Results showed that psychosocial functioning differed across FD classifications. Children with nonorganic characteristics to FD had more behavior problems compared to those with only organic FD. Children with primarily or only organic FD displayed lower developmental skills and their parents had higher emotional distress than children with primarily nonorganic FD. High parent distress was associated with older children who had poor feeding skills, less positive disciplinary practices, and higher social status. The findings imply that clinical services to families often are warranted and that service needs vary depending on the nature of FD. Mixed organic and nonorganic FD occurred in the majority of children, which supports the need for more detailed classification than an organic-nonorganic dichotomy used in prior research.

Infantile depression, nonorganic failure to thrive, and DSM-III-R: a different perspective

A controversy exists regarding the classification of nonorganic failure to thrive within the psychiatric nomenclature. There are a number of DSM-III-R diagnoses that may be applied to NOFTT, including Reactive Attachment Disorder of Infancy (RADI) and Major Depressive Disorder (MDD). The behaviors characteristic of NOFTT are symptomatic of depression, and are similar to those exhibited by infants with anaclitic depression as well as those of the adult with depression. The correspondence of the behaviors of NOFTT and the DSM-III-R criteria for Major Depression are reviewed, as are the conceptual and therapeutic reasons to view NOFTT infants as suffering from Depression.

Disturbances of affect expression in failure-to-thrive

Positive and negative affects were assessed in 28 6- to 36-month-old children with failure-to-thrive and 14 normally growing children in feeding and nonfeeding situations. The roles of malnutrition and severity of organic effects also were examined. Failure-to-thrive children expressed less positive affect in the feeding and nonfeeding situations and more negative affect in feeding than normally growing children. Among failure-to-thrive children, the presence of both acute and chronic malnutrition was associated with heightened negative affect during feeding, whereas the degree of organic contribution had no effect. These results, if replicated, may have implications for clinical assessment and are discussed in terms of current theories of failure-to-thrive.