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....

Should At Risk Children Be Removed From the Home?

The debate presented is should children who are at risk for abuse remain with their families? This is a difficult dilemma and does not allow for a universal position. Unfortunately, there are many factors which influence the predicament. For example, considerations must be given to whether the family is at risk for abuse, or if abuse has occurred. Also, the professional advocates must look at the developmental stage of the child in determining whether more harm is likely to come to the child, and if that harm is greater than that of removing the child from the home. Furthermore, the type of abuse must be examined to determine whether it is neglect, physical abuse, sexual abuse, or psychological abuse. The professional must further examine what the likely outcomes for the child will be. Will the child be placed in a foster care or institutional setting? Will reunification with the family be the likely plan or will permanency in an alternative setting be the hope for the child? Availability of the resources in the community must also be examined. Finally, the objective must remain clear that the child is the point of interest, not political agenda’s, parental bias, and racial or cultural discrimination.

The position this writer takes in the debate of child abuse and reunification with the family is that each specific case must be looked at individually by trained professionals with experience and knowledge in the area of child maltreatment and the outcomes. The influential indicators for each individual decision must include the chronological and developmental age of the child, the ability of the community and professionals to provide intense intervention, the occurrence or risk of the abuse, and the likelihood that the perpetrator of the abuse can alter their behavior. A family simply being “at risk” for child abuse is not enough to justify removal from their home, however, previous occurrences of abuse, neglect, or maltreatment to the child question or siblings does justify immediate action by the professionals, community, and advocacy agencies.

Certain premises have to be universally understood and accepted by advocacy agencies and society to promote and accept the interventions required to adequately address the cataclysm of child maltreatment. In 2006 the United Nations and World Health Organization recognized child abuse and neglect as a major public health issue (Giardino, 2008). Paolo Sergio PinheriroGiardino, 2008). Pinheriro further suggested that a child is dependent on adults completely; therefore more protection should be available, not less, as many private sectors suggest that the government is too interfering with personal family units (Giardino, 2008). As of 2006, in the United States, nine hundred five thousand children were maltreated with sixty three percent of these cases being substantiated neglect, sixteen percent were deemed physical abuse, eight percent classified as sexual abuse and six percent presented as psychological abuse (Giardino, 2008). Furthermore, according to the National Center on Child Abuse Prevention Research, in 2006 One thousand five hundred thirty children died as a result of abuse and neglect (Giardino, 2008). Seventy eight percent of these children were under the age of three (Giardino, 2008). These numbers would suggest that the national plan to address abuse and neglect is not working. Similar to the United Nations, the United States needs to address child maltreatment as a public health issue with funding for research and prevention, intervention, and adequate services to meet the needs of these children. Furthermore, the largest percentage of abuse is in the form of neglect and the largest mortality rate is with children under age three, therefore specific measures need to address and follow the family after the birth of a child to age three.

General understanding of the cycle of abuse is critical to prevention and intervention. Child maltreatment can be recognized in four specific forms, including physical abuse, sexual abuse, neglect and emotional abuse (Child Welfare Information Gateway). The impact of neglect may not be apparent in early stages, but as the child develops it impairs the health and physical development, intellectual development, emotional development and social or behavioral development (Child Welfare Information Gateway). The impact of maltreatment is also dependent upon the child age, presence of adults and services that provide protection or security, the frequency, duration and severity of the neglect, along with the relationship of the child to caregiver (Child Welfare Information Gateway). Early maltreatment impairs the ability of attachment for the child, which has longstanding adverse outcomes (Child Welfare Information Gateway). Furthermore, research finds the first few years of life are sensitive periods for cognitive growth as neural synapses are formed at a high rate (Child Welfare Information Gateway). Research has show that maltreated children have increased rates of cognitive deficits, language delays, and increased rate of later diagnosis of mental retardation (Child Welfare Information Gateway).

The outcomes for maltreated children are devastating and have the potential to be lifelong. A major component of emotional and psychosocial development is the ability to attach to a primary caregiver in the first year of life (Child Welfare Information Gateway). It is estimated that seventy to one hundred percent of maltreated infants form insecure attachments (Child Welfare Information Gateway). Attachment disorders result from attempts to attach by the infant that are met with unresponsive, painful interactions (Ziegler). The attachment dysfunction manifests as an adaption or coping mechanism of the child (Ziegler). Most of these adaptations occur pre-cognitively, therefore become ingrained in the child’s personality unconsciously (Ziegler). Typically, individual therapy, cognitive interventions, and insight can not overcome attachment problems as a form of treatment (Ziegler).

Disorganized attachments are highly correlated to maltreated children (Berk, 2008). These children show contradictory behavior, flat affect, depression, etc. (Berk, 2008). This type of attachment is related to internalizing situations with fear, anxiety and other crisis emotions, and displaying externalized behaviors such as aggression (Berk, 2008). The situation may not be hopeless, however. The continuity of caregiving determines the extent to which the attachment may or may not impair later life (Berk, 2008). If negative caregiving persists, research indicates the likelihood of disorganized later behavior and developmental impairments (Berk, 2008). Research of infant subjects in a Romanian orphanage found that babies placed in a loving home after age four were still able to develop positive emotional relationships and bonds with the caregiver, thus it appears attachment can occur up to age six (Berk, 2008).

A fundamental acceptance of the impact of maltreatment can assist professionals in their pursuit of appropriate placement of the child. Depending upon the age of the child, the severity of the maltreatment, and the likelihood of successful intervention or continued parental offenses must all be taken into account. Foster care is not a permanent solution; rather it is a temporary service responding to a crisis situation (Barbell & Freundlich, 2001). The ultimate objective is to find a safe permanent placement in a safe loving environment (Barbell & Freundlich, 2001). The factors that increase the risk of abuse and neglect include poverty, homelessness, drug and alcohol abuse, and declining community and family support (Barbell & Freundlich, 2001). While the need for these services increases, the availability of these services to meet the needs declines (Barbell & Freundlich, 2001). Many opponents of the interference of state advocacy agencies claim that the foster care system is already overburdened and should not focus on intervention and only interfere with the most severe cases. This is true; the service agencies are stretched thin with little hopes of more funding coming soon. Between 1984 and 1995 foster care placement increased sixty five percent while the available foster parents dropped by four percent (Barbell & Freundlich, 2001). Several changes in policy have occurred in the past twenty years. One significant event is the Adoption Assistance and Child Welfare Act of 1980 which stated that reasonable effort to keep families together be promoted, but alternative permanency solutions need to be created quickly in situations where reunification would not be an option (Barbell & Freundlich, 2001). Again, the foster parent is not a replacement for permanency. The objectives for children where reunification is not possible include adoption and kinship placement (Barbell & Freundlich, 2001). Recently, guardianship has become a viable permanency option for children facing foster care (Barbell & Freundlich, 2001). In 2000, forty three percent of children in foster care were slated for reunification with family, and sixty percent actually returned home (Barbell & Freundlich, 2001).

When consideration is given to remove a child from the home, the actual resources and availability of a safe residential setting has to be considered. There are many placement options, including foster care, kinship care, adoption, and institutionalization. However, each individual case needs to be examined to determine if the harm at the current home setting is greater than the harm at the placement options. For example, if the only available placement option for a 3month old infant is institutionalization, but the form of maltreatment occurring at home is malnutrition, than obviously the risks for cognitive, social and emotional development from disrupted attachment in the institutional setting far outweigh the cost of immediate intervention in the home to teach the parent health and nutrition skills. Yet, if the malnutrition is simply an indicator of far worse neglect and abusive acts such as physical abuse, emotional detachment from the infant, severe emotional neglect, etc. than the temporary placement in an institutional setting may be appropriate with the hopes of obtaining an alternative setting in the near future, such as foster care or a placement with a relative.
In theory, maltreatment in any form is unacceptable. However, reality concedes that there are not enough adequate alternative placements for children who suffer maltreatment. The ultimate goal has to consider whether the family situation is open and receptive to intervention, training, and learning a new form of parenting and caregiver response. If this is possible, than intervention is the choice. If the family dysfunction is so great that the likelihood the abuse will continue or present again in the future, than alternative placement must be sought.

The key to the crisis of child maltreatment must focus on prevention. Strategies need to not only recognize the factors that increase the likelihood of maltreatment, but have the resources to support the at risk family during the sensitive periods of child development. Recognition fact that reoccurrence is high with many forms of maltreatment, especially those that are psychologically derived such as sexual abuse, should indicate an immediate and required intervention for specific at risk populations. In these specific situations, reunification should never be an option. The focus must remain on the child and the child’s ability and potential for healthy development when services are required to intervene. Sensitivity and trust are likely absent in these children’s working models of the world around them, so it is the community and agency’s responsibility to introduce these concepts. Once intervention has concluded, follow up services must be continued along with supports within the immediate environment to ensure a safe haven for the child’s development.

A 2006 report to the United Nations in which he proclaimed that no violence against children can be justified, yet all violence against children is preventable. In conclusion, the debate over removing children at high risk for maltreatment must be individualized to the unique situation of the family and the child. The developmental and chronological age must guide the appropriate interventions with special attention given to the critical formation of healthy attachments. Removal of a child should not be an automatic response, but if the child is in a life threatening situation, victim of sexual or physical abuse, immediate action must be taken. Simultaneously, the risk factors associated with the likelihood of maltreatment must be addressed by the community and social services, with adequate funding and support to ensure that children have a safe haven. Finally, when children are removed, a thorough investigation of the allegations, as well as, a review of the current developmental abilities of the child should be reviewed to determine the impact of the maltreatment.











References:
Barbell, K., & Freundlich, M. (2001). Foster Care Today. Washington DC: Casey Family Program National Center for Resource Family Support.

Berk, L. (2008). Infants, Children and Adolescents. Boston: Pearson.

Child Welfare Information Gateway. (n.d.). Understanding the Causes of Neglect. Retrieved August 14, 2008, from Not Alone: http:www.enotalone.com/article/9889.html

Giardino, A. P. (2008). child maltreatment: Is the glass half full yet? Journal of Forensic Nursing , 1-3.

Ziegler, D. P. (n.d.). Understanding and treating attachment problems in children. Retrieved February 5, 2010, from Attachment Disorders: http://www.addictionrecov.org/paradigm/P_PR_F98/Attachment_Di...



Take a minute and share your thoughts or your story with us... Should a child be removed if they are at risk? What severity of abuse or neglect requires a child be removed? Thoughts, ideas, etc....