Friday, April 23, 2010

Non Organic failure to thrive may be misinterpreted as Neglect or Abuse...

Non organic failure to thrive can be related to many factors which increase the risk of malnutrition including geographic location, poverty, attachment disorders, and parental neglect. Socioeconomic status impacts growth and health through nutrition and health care availability (Meszaros, Meszaros, Szmodis, Pampakas, Osvath, & Vlgyl, 2008). Malnutrition is linked to significant delay in growth, and even after the nutritional intake increases, the delays may not be reversed (Meszaros, Meszaros, Szmodis, Pampakas, Osvath, & Vlgyl, 2008). Studies of malnourished children in Hungary by Meszaros and associates found that phsycal attributes and performance were significantly decresased when compared to a control group of non-malnourished children (Meszaros, Meszaros, Szmodis, Pampakas, Osvath, & Vlgyl, 2008).

When geographic and situational factors are not the cause of the malnourishment, often neglect or impaired parental attachment is suspected. However, this again, may relate to socioeconomic standards. Poverty is linked to abuse and neglect according to the National Incidence Study of Child Abuse and Neglect (Dubowitz, Papas, Black, & Starr, 2002). The estimate of neglect is forty four times more likely to occuring families with less than fifteen thousand dollars annual income (Dubowitz, Papas, Black, & Starr, 2002). Furthermore, there is a strong association between poverty and impaired function (Dubowitz, Papas, Black, & Starr, 2002). Besides the ultimate outcome of failure to thrive, Neglect impacts health and physical development resulting in skin infections, medical problems, malnourishment and impaired brain development (Child Welfare Information Gateway).
In the past fifty years, however, the non organic failure to thrive has been correlated not only with neglect, but more specifically, as an emotional breakdown in caregiving and attachment impairment (Goldson, Milla, & Bentovim, Summer 1985). Many states require medical professionals to report cases of failure to thrive to Child Protective Services (Kotelchuck & Newberger, 1983). Attachment is the positive bond between people that results in a pleasurable experience (Berk, 2008). By the end of the first year an attachment between an infant and a familiar caregiver is the norm in development (Berk, 2008). Theories suggest that the attachment is based on the survival need of the infant, with the quality of attachment directly influenced by the caregiver responser (Berk, 2008). A sense of security, the first building blocks of the infant’s personality, and future relationships are all believed to be affected by this initial attachment (Berk, 2008).

Goldson and associates conducted a case study to discuss and propose a psychosocial classification of failure to thrive (Goldson, Milla, & Bentovim, Summer 1985). The hypothesis suggests that besides organic and non organic failure to thrive, there may be another category which encompasses the cases in which the child’s psychological responses to food and intake may be directly linked (Goldson, Milla, & Bentovim, Summer 1985). Many familial responses can be indicated as influences to the occurrence of failure to thrive, but rather than the assumption that these responses are the cause of the failure to thrive, they may be the result and continuing to enable the occurrence.

The case study was conducted at the Hospital for Sick Whcildren during 1983 (Goldson, Milla, & Bentovim, Summer 1985). The subjects of the study included twenty four children in the Gastroenterology ward with a diagnosis of Failure to Thrive (Goldson, Milla, & Bentovim, Summer 1985). The diagnostic standards required weight of the child be two standard deviations below the previously established weight trajectory (Goldson, Milla, & Bentovim, Summer 1985). Three subject groups were included in the study, including eleven children with organic causes for the failure to thrive (Goldson, Milla, & Bentovim, Summer 1985). The second group included six children thirteen to thirty five months with the diagnosis due to decreased nutritional intake but no organic disease established during evaluation (Goldson, Milla, & Bentovim, Summer 1985). The third group included seven children of mixed gender ages two months to six years with ongoing organic illnesses or problems requiring medical intervention (Goldson, Milla, & Bentovim, Summer 1985). These children had a history of refusing to eat or poor feeding skills, and the illnesses suffered ranged in severity (Goldson, Milla, & Bentovim, Summer 1985).
One challenging case described in the literature includes a a child who was referred to the clinic at six months of age for decreased weight gain (Goldson, Milla, & Bentovim, Summer 1985). According to maternal report, pregnancy and delivery were normal and birth weight was five pounds (Goldson, Milla, & Bentovim, Summer 1985). Mother reported weight increased but there were some difficulties with feeding early on (Goldson, Milla, & Bentovim, Summer 1985).At six months dietary and medical support services were implemented with no improvement followed by two to three months of the child refusing food, vomiting after intake, and bouts of diarrhea (Goldson, Milla, & Bentovim, Summer 1985). Admission to the hospital was required with an admitting diagnosis of failure to thrive due to decreased nutition (Goldson, Milla, & Bentovim, Summer 1985). Weight was at least two standard deviations below the norm but the head and length correlated with normal rate of development (Goldson, Milla, & Bentovim, Summer 1985).

Immediately after the admission, nurses reported difficulty with the mothers attitude and behavior (Goldson, Milla, & Bentovim, Summer 1985). Tension was noted with the medical staff, along with reports of defensive and interfering behavior (Goldson, Milla, & Bentovim, Summer 1985). The physician, along with support professionals including the social worker attempted to investigate the family situation through interview and discussions with the family (Goldson, Milla, & Bentovim, Summer 1985). It was noted that there were difficulteies with the parental relationship and stress at home (Goldson, Milla, & Bentovim, Summer 1985). These factors are often associated with caregiver attachment impairments and neglect.
During this period the nurses and medical staff began to report difficulty with feeding and refusals of intake by the child (Goldson, Milla, & Bentovim, Summer 1985). The physician conducted further testing and determined slight tongue thrust and swallowing difficulty, but no neuro motor etiology for the problem (Goldson, Milla, & Bentovim, Summer 1985). After further investigation it became apparent that the mother was overly concerned about the decreased intake early on that she had began becoming more forceful with the feedings and in response the child became more resistive to the intake (Goldson, Milla, & Bentovim, Summer 1985). Thus, the feeding experience became a negative one for the chid and he began to refuse intake, become more fussy during feedings, etc. This increased the unpleasantness of the experience leading to continuance of difficulties (Goldson, Milla, & Bentovim, Summer 1985).

Simultaneously, the mother began to have decreased self esteem as a caretaker, leading to marital and family problems in the home (Goldson, Milla, & Bentovim, Summer 1985). The hospital staff misinterpreted the mother’s responses and labeled her as a neglectful caretaker, increasing her self doubt and defensiveness (Goldson, Milla, & Bentovim, Summer 1985). These factors all helped to perpetuate the negative feeding experience, encouraging the continuance of refusals for intake (Goldson, Milla, & Bentovim, Summer 1985).

The case study supports the theory of Goldson and associates that there may be an interaction of organic, psychological and environmental factors resulting in the outcome of failure to thrive (Goldson, Milla, & Bentovim, Summer 1985). Previous attempts to classify failure to thrive as organic or non organic do not allow for recognition of the child’s psychological response or role in the diagnosis of failure to thrive (Goldson, Milla, & Bentovim, Summer 1985). Thus, family relationships and home environment may play a part in failure to thrive, but do not necessarily indicate neglect (Goldson, Milla, & Bentovim, Summer 1985).
Similar case studies have suggested that in non organic failure to thrive, there may be influences besides failed attachment and poor caregiving, such as ecological stress factors (Kotelchuck & Newberger, 1983). These factors may include parent and child separation, poverty, and family stress (Kotelchuck & Newberger, 1983). Furthermore, according to current literature based on hospital case studies, most families with a failure to thrive child are intact, larger size, parental age is in their twenties, and no correlation to social class has been found (Kotelchuck & Newberger, 1983). However, it is important to note, that the families mentioned in these case studies have their child in treatment, indicating a desire to improve their child’s situation and suggesting they have the means to seek such intervention. This may not be a true representation of all failure to thrive families, and may bias the sample leading to invalid conclusions.

This is a pretty scary thought... The system is here to protect children and families, yet, the warning signs and symptoms are often misinterpreted and assumptions are based on other characteristics than the facts. How hard would it be to examine the case objectively? How often do you think this really happens? Have you ever had a similar experience? Feel free to share your thoughts on this....

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