CHILDREN WHO FAIL TO THRIVE - PART 2 potx

14 CHILDREN WHO FAIL TO THRIVE to guide Frederick away from occult, magic, and secret paths, and directed him to more dispassionate scientific experimentation. At that time Frederick developed a rigorous approach to design, measurements, and evaluation. Under Frederick’s aegis, studies were made of the effects of deprivation in children, albeit in the realms of language acquisition: in order to establish what was the original language of mankind, new-born infants were reared by foster-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 foster- mothers. No spontaneous acquisition of Hebrew, Greek, Latin, Arabic, or the languages of the parents to whom the children were born occurred, for in those silent domains the subjects of the experiment all died, although it is not recorded if infection, lack of hygiene, disease, or silence caused their passing. The conclusion was that Frederick II had the will and intellectual wisdom to seek the truth by means of experimentation at a time when passive acceptance was the established order of the day. Frederick is seen as the first scholar to observe and document the serious effects of deprivation in children, but, like many other curious and inquisitive observers who followed, he failed to find appropriate answers to the questions he asked. There were sundry studies on the fringes of Renaissance enquiry, but in the seventeenth century Sir John 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. He recommended ‘three Doctors’ (figuratively speaking of course) to increase an awareness 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 stated that 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 put it: Use three Physicians still, First Doctor Quiet, next Doctor Merryman, and Doctor Diet. Those who work with children who fail to thrive and their families will find this quotation very apposite, as it clearly emphasises the importance of ade- quate nutrition and the atmospheres that should surround it. The quotation indicates that those ‘three wise men’ are often absent from the nutritional lives of what are often sad, undernourished children, and of parents who may be anxious, frustrated, demoralised, unsuccessfully trying to feed the child, or neglectful and ill informed about the child’s nutritional and nurturing needs. Documentation of child deprivation and its outcome is very scarce and we know that during the Middle Ages children were portrayed as adults in small bodies (Ari`es, 1973). The artist William Hogarth (1697–1764) pictured many 4 D.N.B. (1917), viii, 1269–72. HISTORICAL PERSPECTIVE OF FAILURE TO THRIVE 15 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-dwarfism syndrome by showing a child eating garbage, M¨unchausen Syndrome by Proxy, overt abuse, and acute neglect of children’s nutritional, emotional, and physical needs. Hogarth tried to draw public attention to the plight of children by depicting different accidents which he observed and which had an enormous effect on him. In 1738 he produced an engraving entitled ‘The Four 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 notice the ragged girl helping herself to the food on the ground. Institutions for the care of ‘foundlings’ (children, usually illegitimate, who were abandoned) have a long history. There were ‘foundling hospitals’ in numerous European cities, and these have been documented. As early as the seventh and eighth centuries there were such establishments in Trier on the Mosel (Augusta Treverorum, the oldest town in Germany), Milan, and Mont- pellier (to name but three such), and in the fourteenth century a famous foundling hospital was created in Venice. Paris and Lyons acquired important foundling 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 ille- gitimate girls (or girls whose parents were unable to support them). These State-supported schools provided very high standards of education, and the Ospedale della Piet`a’s musical performances were much appreciated and justly renowned (Blom, 1966). Indeed, interest in disadvantaged children accelerated during the eigh- teenth century, a time when rational enquiry of all kinds proceeded apace. One of the best-known foundling hospitals was that established by Captain Thomas Coram (c.1668–1751), shipwright, seafarer, trader, colonist (he was involved in both Georgia and Nova Scotia), and philanthropist. 5 Shocked by the common sight of infants exposed and dying in the streets of London, he agitated for the creation of a foundling hospital, and laboured for 17 years to that end. A Charter was obtained, considerable sums subscribed, and the first meeting of the guardians was held in 1739. Some houses were acquired at Hatton Garden, and the first children were admitted in 1741. Eventually, a largerparcel of land waspurchased north of Lamb’s ConduitStreet, 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 by numerous individuals, including Hogarth, who presented his fine portrait of 5 D.N.B. (1917), iv, 1119–20. 16 CHILDREN WHO FAIL TO THRIVE Coram to that hospital in 1740. Georg Friederich H¨andel (1685–1759) gave concerts 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 Hospital 6 admitted any child under 2 months of age who was free from certain specified diseases, without ques- tion or any attempt to identify its parentage. A basket was suspended outside the entrance-gate in which unwanted infants were deposited, and a bell rung to inform staff of new arrivals. So great was demand that a system of balloting for admission had to be introduced, as fights had occurred outside the gates among those mothers wishing to get rid of their unwanted babies. Grants were made by Parliament from 1756, on condition that all children orphaned were admitted, and in 1757 branch-hospitals had to be opened at Ackworth, Shrewsbury, Westerham, Aylesbury, and Barnet to cope with the 3,727 chil- drenfor whom admission was sought. This general admission wassoonfound to be a mistake, for of the 14,934 children received during the three years it was 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 persons were paid by parents to bring infants from all over the country to the London Hospital, but few of those children, through brutality or criminal negligence, ever even reached ‘Coram’s Fields’ alive. So abused was the system that State grants ceased entirely in 1771, and from then onwards the foundation had to depend on private philanthropy for its funds, and admission was changed to a process of selection. Eventually, a child could only be admitted upon the personal application of the mother, and the children of married women or widows 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 were advantages 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 institutionalised environment, except for very short periods, became recognised as being bad for 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 the outcomes of children deprived of individual care were shocking, in that they 6 Encyclopædia Britannica (1959), ix, 559–60. HISTORICAL PERSPECTIVE OF FAILURE TO THRIVE 17 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. Nutritional and 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, and all-round gross negligence affected their physical, cognitive, emotional, and social 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, whereby the 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 few parents 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 super- seded by a number of similar enactments leading up to the more modern and comprehensive Children Act (8 Edw. 7, c.67) of 1908. Abandoned, rejected, neglected, cruelly treated and orphaned children were cared for in the large orphanages or hospitals. The poor outcomes of institutional care were widely acknowledged, and many professionals and researchers expressed their concerns. However, Holt and Fales (1923) stated that, given the appropriate conditions, strikingly good health and excellent nutrition can be maintained in children obliged to live in institutions. After outlining the hazards and dangers for children being cared for in the infant ward, Joseph Bremeau (1932) made eight recommendations for prevention, one of which was ‘one nurse for two babies, minimum’. Apart from stressing the nutritional needs of children, doctors increasingly began 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 healthily and vigorously and to recover more quickly from illnesses, babies need ap- propriate physical and emotional contact with care-givers, as the absence of such continuing nurturance and physical intimacy can bring about anxiety and fretting in children, disrupting biological functions. Development of awareness for the necessity of emotional care was well described by Montagu (1978). In his chapter on ‘Tender Loving Care’ he 18 CHILDREN WHO FAIL TO THRIVE described high mortality rates in institutions, and related an interesting anec- 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 ancient hag-like woman who was carrying a very undernourished infant. The doctor enquired of the director the identity of the old woman and was told that she was ‘Old Anna’: when the staff at the hospital had done everything medically they could do for a baby, and it still failed to thrive, they handed it over to ‘Old Anna’, who succeeded in remedying matters every time. She fed the child, encouraged it to eat, was patient, held it gently, talked to it, rocked, giving tender attention plus the close physical contact which every baby needs: it 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 which she 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, hospitalisa- tion, and maternal deprivation on infants. During the 1940s studies began to emerge postulating that emotional deprivation per se could affect phy- sical growth, and many claimed that deprivation in infancy would lead to irreversible impairment of psychosocial functioning in later life. Some of the best 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 five years 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 their mothers with a group raised in virtual isolation from other infants and adults. Spitz stated that physical illnesses, including infections, are contracted more frequently by infants deprived of environmental stimulation and maternal care than those not so deprived. The failure-to-thrive syndrome, according to Spitz, is a direct result of inadequate nurturance: indeed he actually doc- umented long-term intellectual deficit in the survivors of the non-nurtured group. Of the deprived group, 37% had died by 2 years of age, compared with none in the adequately mothered group. Spitz stated that a condition 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 methodological and 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 HISTORICAL PERSPECTIVE OF FAILURE TO THRIVE 19 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 par- ents in their natural homes) would be more appropriate. Nevertheless, these studies proved (with the addition of Bowlby’s work) to be significant in a heuristic sense, and have been important catalysts in generating research and informing policy and practice. CAUSAL MECHANISMS The association between maternal deprivation and failure to thrive has led some investigators to hypothesise the existence of a physiological pathway whereby emotional deprivation affects the neuro-endocrine system regulat- ing growth. Several studies were done to test growth-hormone efficiency. The mecha- nism in dwarfism was studied extensively in attempts to answer the question ‘what factors play a role in growth-hormone arrest and what happens and under what circumstances are they switched on again?’. These studies con- centrated on various forms of growth failure, but particularly on dwarfism without organic cause. Dwarf children were defined by Patton and Gardner (1962) as being below the 3rd percentile in height, with weight below that expected 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 emotional disturbances might have direct effects on intermediary metabolism so as to interfere with the anabolic processes. The production and release of several anterior pituitary hormones are influenced by hypothalamic centres, which are, in turn, recipients of pathways from higher neural centres, particularly the 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 hormonal insufficiencies 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 the food-intake of individuals with dwarfism syndrome in Bristol. Their exhaus- tive clinical, biochemical, and endocrine tests on all the children ruled out the operation 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 of dwarfism 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 20 CHILDREN WHO FAIL TO THRIVE 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 had scanty subcutaneous tissue. They were the first to point to ‘chronic grief’ as one of the causes of dwarfism. They studied over one hundred individuals with dwarfism syndrome between 2 1 / 2 and 15 years of age, but were not able to find any organic cause for the stunting in growth. The nutritional history of these children clearly indicated that there were feeding problems for a major part of their lives (and in some cases since birth): the authors postulated that once a child became undersized, it continued with basically reduced protein and calorific requirements, and, the pituitary function having become adap- tively reduced, it failed to function normally when the diet improved. Some children, therefore, remained small though apparently well nourished. Talbot and his colleagues treated them with pituitary hormones and discovered that some 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 the backgrounds of these children were grossly problematic, and listed the fol- lowing features in 24 of them: r 34% rejection; r 14% poverty; r 14% mental deficiency; r 19% chronic grief; r 14% maternal delinquency; and r breakdown in family and marital relationship in 14% of cases. No abnormality was found in only 5% of cases. In seven well-nourished children no abnormality was found in three cases, maternal delinquency or breakdown in three, and rejection in one. Four ofthese children withdisturbed maternal relationships were stunted in growth, but on the surface appeared well nourished. The outcomes suggested that the intake of food was not the whole answer to the cause of the dwarfism, and led other researchers to pursue the hormone studies. In 1949 Bakwin concluded that failure to thrive in institutions is the re- sult of emotional deprivation, and that emotional reactions arise principally in response to sensory stimuli. He believed that children who are hospi- talised should receive attention and affection, and should often be held in the 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. He described the appearance and psychological expression in the following ways: HISTORICAL PERSPECTIVE OF FAILURE TO THRIVE 21 Appearance Psychological expression Listlessness No interest in food, accepted passively Quietness Emaciation Poor appetite Immobility Unhappiness Withdrawal Absence of sucking habits Unresponsiveness No interest in surroundings Insomnia Poor tone Miserableness Seldom crying Lying motionless in bed Slow movement Sunken cheeks Bakwin associated poor growth development and psychological presenta- 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. Widdowson (1951) reported in The Lancet the effects of psychosocial de- privation on children’s physical growth. She replicated Spitz’s findings that adequate 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 two German orphanages where she was stationed as a British Army medical of- ficer. Each orphanage accommodated around 50 boys and girls of a wide age range between 4 and 14 years. A dietary supplement, which was expected to produce faster weight gain, was introduced as an experiment in one or- phanage, using the other as a control. Contrary to expectation, it was the control group which gained weight and grew a little faster during the exper- imental period of six months. Afterwards it was discovered that the matrons of the two orphanages had swapped over at about the time of the start of the dietary supplement. The matron in charge of the experimental group (who had transferred to the control group) had been a kindly, caring, and warm person, but the matron originally in charge of the control group (who had transferred to the experimental group) was harsh, a hard disciplinarian who tended to harass the children at meal-times. Such harsh behaviour could well have caused some achlorhydria and also anorexia (though it is unlikely that the children would have been allowed to leave anything on their plates). One may speculate that the dietary supplement was wasted. This study suggests that nutritional intake (to be beneficial) has to take place in relative 22 CHILDREN WHO FAIL TO THRIVE calmness and in an anxiety-free state, and that non-nutritional emotional fac- tors play an important role in digestion and absorption. Indeed, one of the indices of basic trust and security in an infant (in Erikson’s sense) is stable feeding 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 will not put on weight, so feeding it quantities needed for its age is the first re- quirement. The second requirement is calm and friendly interaction during feeding/eating times, and the third is sensitivity and awareness of a child’s personal characteristics, i.e. temperament, and of some feeding difficulties (such as oral-motor problems or other illnesses) which make eating uncom- fortable or painful. 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 food more and are more eager to eat when we are happy and in the company of people 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 developmental delays, similar to those found among institutionalised children, were repli- cated on infants and young children living at home. Studies of such children and their families have shown that the most commonly identified precursors to these growth problems are emotional disturbance and environmental deprivation—with the wide range of psychosocial disorganisation that these concepts imply. Deprivation often involves rejection, isolation from social contact, and neglect. These associations with poor growth have been delineated in the context of maternal personality problems, stemming from the mother’s own early background, family dysfunction, immaturity, social isolation, and mental-health problems. Other psychological difficulties have been found to stem from the manner in which mothers nurture their small infants. The prevailing view was that socio-emotional deprivation could be the cause of some cases of short stature, and that the most likely aetiology was 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 intro- duced by Henry Kempe and his colleagues in 1962, theorists, researchers, and HISTORICAL PERSPECTIVE OF FAILURE TO THRIVE 23 clinicians have explored the causes of child abuse and neglect, including fail- ure to thrive. For a considerable time the medical–psychiatric model of the causation and treatment was favoured, attributing the blame for its occur- rence to the pathological personality structure of the mother and her history of having herself been abused and neglected as a child. Let us look at a few studies conducted at the time and their preoccupation with maternal failings. Coleman and Provence (1957) presented detailed reports of two infants from middle-class families in whom they postulated retardation of both growth and development resulting from insufficient stimulation from the mother and insufficient maternal care. In the first case the child was difficult to feed and presented as generally passive and difficult to enjoy. When the infant 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 from her infant: she stopped breast-feeding on the fourth day after birth because she said she was afraid she would smother the child, and spanked the infant because its crying drove her wild. She alternated between feelings of depres- sion and helplessness over the baby’s poor development. The baby was not planned or wanted and the mother resented breaking her career. The authors did not make any distinction between these two infants and mothers. It is clear, however, that both babies were undernourished and failed to thrive: one presumably because of feeding difficulties and maternal grief; and the second 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, brief contacts on the wards, social-work reports, unstructured interviews with the fathers, 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 inadequate mothering, including: r limited abilities to perceive accurately the environment, their own needs, or those of their children; r limitations of adaptability to changes in their lives; r adverse affective states; r defective object-relationships; and r limited capacity for concern. Since character disorders (in the view of many) are untreatable, they sug- 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 present character disorders, it would be wrong to say that all mothers or the majority [...]... of children: those who were neglected; those who failed to thrive; and those with a combination of failure to thrive and neglect They found that cognitive performance of the 44 CHILDREN WHO FAIL TO THRIVE group of children who failed to thrive because of neglect was significantly lower than was the case among those from the FTT or neglect-only groups This study indicates that FTT due to neglect is particularly... categories: 40 CHILDREN WHO FAIL TO THRIVE 1 Children with subtle neuromotor problems These children may have difficulty eating because of oral-motor disturbances For example, neurological abnormalities in oral-motor or gastro-intestinal functioning have been observed by Mathisen et al (1989) Lewis (19 82) suggested that oral-motor abnormalities can contribute to non-organic failure to thrive, including... three-quarters of an ounce of cheese A less rich source of protein could be provided from cereal foods NON-ORGANIC FAILURE TO THRIVE The term ‘non-organic failure to thrive is applied to children whose failure to grow normally is due to psychosocial reasons in their environment rather than as a result of any medical illness One of the problems in the literature is that traditionally non-organic failure... 1995; Iwaniec & Sneddon, 20 01a; Iwaniec & Sneddon, 20 02) 36 CHILDREN WHO FAIL TO THRIVE EATING BEHAVIOUR AND UNDER-NUTRITION IN NON-ORGANIC FAILURE TO THRIVE Of course, not all children who have eating problems are associated with neurological abnormalities or illnesses affecting their appetite and digestive processes, and therefore contributing to reduced growth velocity Some children live in homes... useful to separate them (Humphry, 1995) Infants who fail to thrive may have some organic features that contribute to, but do not explain, their lack of growth All failure -to- thrive children have at least one organic problem in common, that of malnutrition (Bithoney & Newberger, 1987) This may help to explain why some children with an organic impairment such as cardiac disease or cleft lip may fail to thrive, .. .24 CHILDREN WHO FAIL TO THRIVE of mothers whose children fail to thrive have personality disorders The label can also be a facile and meaningless designation, devoid of useful implications Similar and different signs of psychopathology have been identified among mothers of failure -to- thrive children Barbero and Shaheen (1967) found mothers in their... under-nutrition that brings about failure to thrive carries a high risk of negative effects for intellectual development later in life (Iwaniec, 20 00) The serious consequences of failure to thrive or under-nutrition on developmental outcome have been well documented over the years (Oates et al., 1985; Hutcheson et al., 1997; Grantham-McGregor et al., 20 00) Children who fail to thrive are thought to be... shows low weight-for-age or weight-forheight (WHO Expert Committee, 1995) PREVALENCE OF FAILURE TO THRIVE Although failure to thrive usually occurs early in a child’s life, its effects and consequences can be observed at the older toddler stage, middle childhood, 30 CHILDREN WHO FAIL TO THRIVE or even adulthood (Sneddon & Iwaniec, 20 02; Iwaniec & Sneddon, 20 02) r Estimates of prevalence have varied from... rates of 3.9% in children who failed to thrive The calculations were based on a sample taken from all children born in 1991 Wright et al (1994), endeavouring to unravel the prevalence and reasons for FTT, examined various environmental factors which they thought might have contributed to an increased rate of occurrence of the syndrome They classified all children who failed to thrive into three categories,... tragic case indicates the necessity to respond speedily to worrying signs and to avoid the ideological belief that only very few children fail to thrive because of illness There were many serious signs indicating the necessity for a more comprehensive medical investigation, but they were not taken on board 34 CHILDREN WHO FAIL TO THRIVE MALNUTRITION AND FAILURE TO THRIVE Strictly speaking there is a . aetiology and controlling mechanisms of failure to thrive. SUMMARY Failure to thrive is as old as human history. There have always been children who fail to thrive, and, although they were not labelled. into three categories: organic, non- organic, and combined. Organic failure to thrive is thought to result from illnesses or genetic conditions, whilst non-organic failure to thrive may de- rive. small child who has small parents to be la- belled as failing to thrive, that child would have to be low in weight for height, or demonstrate poor weight-gain velocity, since weight-for-age would normally