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Journal of the American Academy of Child Psychiatry, 22, 4:322-328, 1983 Failure to Thrive: A Controlled Study of Familial CharacteristicsMilton Kotelchuck, Ph.D., M.P.H., and Eli H. Newberger, M.D
The syndrome "failure to thrive" (FTT) is used to describe infants and children who fall below the third percentile in height and weight when no organic basis for this deviance is found. A commonly held theory on the origin of the FTT syndrome posits the cause as an interactional affective problem between the mother and her infant (Bullard et al., 1967; Fischoff et al., 1971). The pathogenic mechanism is hypothesized to be a failure to form a normal mother-child bond and a consequent deficit in the infant's growth. Nutritional and child developmental factors are seen' in the formulation to be secondary to interpersonal problems (Evans et al., 1972; Newberger et al., 1976; Patton and Gardner, 1972). The interactional etiologic theory derives from the vast body of psychological literature suggesting the importance of the child's early relationship to his mother and the severe negative consequences of separations or distortions of this relationship (Ainsworth, 1969; Bowlby, 1969). Moreover, there is a strong similarity in physical appearance between infants who fail to thrive and the classic institutional cases of maternal deprivation (Spitz, 1945); both are small, lethargic, sickly children. Given this similarity of the child's physical symptoms and often overly distressed mothers, Talbot et a1. (1947), made the logical connection and hypothesized that failure to thrive resulted primarily from a maternally induced failure of mother-child bond formation. This theory has received widespread acceptance. Clinically, FTT is often thought to be the physical manifestation of maternal neglect or even abuse (Bullard et al., 1967; Kempe, 1971). Indeed, in many states, physicians are mandated to report FTT cases to the state's child protective services. Possible termination of the mother's custody is frequently a consideration in the child's treatment (i.e., removing the child from the "causal" agent of his or her illness). Yet, there is little direct evidence to support the hypothesized association between infant growth failure and maternal characteristics. The clinical literature reports that FTT mothers are psychopathologically burdened; that they are depressed (Elmer, 1960), alcoholic (Leonard et al., l966), highly anxious (Elmer, 1960; Togut et at, 1969), and have character disorders (Fischoff et al., 1971). But the value of these reports are somewhat limited, since they are based on a limited sample size and none has a control group. There is an assumption of psychiatric causation. Nonpsychiatric variations in maternal and familial characteristics which also might make the child at risk for growth failure-maternal inexperience, recent stress, parent-child separations, poverty, etc.-have not been fully examined. Indeed, a clear picture of the demographic and ecologic characteristics of FTT infants and their families has yet to be established. Several studies have attempted to examine maternal and child characteristics based on retrospective summarizing of hospital FTT case reports (Glaser et al., 1968; Hannaway, 1970; Riley et al., 1968). FTT families are generally intact, although somewhat larger than usual size (Glaser et al., 1968; Whitten et al., 1969). Parents are generally in their mid-twenties (Hannaway, 1970), and come from all social classes. FTT is not a phenomenon limited to poor children (Glaser et al., 1968). Given the wide variations in hospitals examined and the lack of a comparison sample in all of these studies, no very distinct FTT patterns emerge from these analyses. Moreover, retrospective hospital case record studies are restricted in the range and quality of data which can be evaluated. Too often critical topics, e.g., family networks, parent-child separations, child behavior problems, maternal upbringing, pregnancy experiences' are not mentioned systematically in the records. The contribution of the child's own characteristics to his growth failure also remains to be evaluated (Bell, 1971; Pollitt, 1973). Controlled studies of the characteristics of mothers of FTT are now finally appearing in the psychiatric and pediatric literature (Fitch et al., 1976; Pollitt et al., 1975). Pollitt et a1. (1975), the strongest of the studies, found almost no distinguishing ecological or psychopathological differences between the mothers of FTT and control children. Unfortunately, in the studies to date, the selection of control or comparison groups appears to differ on social class and/or ethnic background from their FTT groups, thereby somewhat weakening the value of these reports. The role of maternal or social environmental factors in the etiology of FTT still remains basically unproven. A more complete picture of FTT familial characteristics remains a necessary first step to understand the etiology of FTT and to assess the specific hypothesis that FTT is maternally induced. The present study derives from a larger study of risk factors associated with social pediatric illnesses (Newberger et al., 1977). Social pediatric illnesses are illnesses or trauma of childhood resulting primarily from the child's physical and social interaction with his environment; they include child abuse, neglect, FTT, accidental injuries, and ingestion. This paper will present a new and more detailed analysis of the families with FTT children, based on data from original study. This paper also strengthens the methodology of the original larger Newberger et a1. (1977) study by using a more powerful control group design. The goal of the study is to investigate familial and ecological characteristics of the FTT and control families, in order to determine which factors increase the child's risk for FTT, and to begin to examine the assumption of maternal causation of FTT. The conclusions of the study are limited by information which is obtainable from clinical interviews; the study does not directly test maternal psychopathology or directly observe mother-child interaction. Sample and MethodAll children under 4 years of age admitted to Children's Hospital Medical Center, Boston, with a social pediatric illness diagnosis were eligible for inclusion as "cases" in the original Newberger et al. (1977) study. All cases of FTT fell below the third percentile, both for height and for weight on the Boston Growth Standards (Stuart, 1939), had no recognizable organic etiology for the growth failure, and had primary discharge diagnoses of nonorganic FTT. The controls were also inpatients at Children's Hospital Medical Center with acute short-term medical illness diagnoses such as pneumonia, meningitis, etc. Families of children failing to thrive and control families were matched on a 1 to 1 basis in terms of same race, same age (within +/- 3 months), and a similar socioeconomic status (whether or not the Department of Public Welfare paid for the hospitalization). Data were collected over an 18-month period of time. In the present
study, 42 families of children with FTT and 42 families of matched control
children are examined. The mothers of all study children were interviewed
using a standardized precoded interview schedule during the children's
hospitalization. All interviews were conducted by sensitive, trained
interviewers and lasted approximately 1 hour. All interviews were voluntary,
and informed consent was obtained. The interview focused on historical
and contemporaneous stress relating to familial, environmental, and
child development realities. Specific areas explored included family
structure and residence, socioeconomic status, characteristics of the
pregnancy, parent-child separations, maternal stresses, family support
and isolation, and child behavioral characteristics. (Details of the
topic and coding of the specific questions are The data were analyzed by performing T test or chi-square tests between the case and control groups on an item by item basis. T tests were used where the underlying scale was ordinal, chi-square where the underlying scale was nominal. Subsequently, a discriminant function analysis of the data was performed. All statistics were calculated on an IBM 360/55 using Data-Test (Armor and Couch, 1972). The present analyses improve upon the original analytic approach of the larger Newberger et a1. (1977) study by using a directly 1:1 matched control group rather than the original study's overall unmatched comparison group. Sample CharacteristicsAs shown in table 1, the cases of FTT in our sample are predominantly young; no child is over 36 months of age; 81 % are under 18 months, and 71% under 12 months of age. The sample is predominantly white (83%), and the families are not generally dependent on the Department of Public Welfare for medical assistance (67%). The majority of the patients in the sample are male (69%). The matching families had exactly the same demographic distribution. Family Structure
As shown in table 2, demographic measures of family structure do not distinguish cases of FTT from the comparison group. Family size, age of parents, index birth order, maternal marital status, and duration of the marriage are similar in both groups. Social Class Characteristics of the FamilySince the FTT group and their controls were initially matched on a crude index of socioeconomic status (SES), no differences emerge on the more comprehensive Hollingshead (1965) SES index. Not surprisingly, few social class measures reveal differences. There are no significant case-control differences in either maternal or paternal job levels or length of time employed. Mothers of FTT children have slightly less education than the control mothers (p < 0.09), while there are no educational differences for the fathers. This results in a significantly larger discrepancy between the parents' education in the families with FTT children, than in the control families (1. 7 vs. 0.2 years, p < 0.05). Housing is similar, although the families of children with FTT live in slightly fewer rooms (p < 0.10). Similar access to medical care with a private physician is observed. PregnancyNo significant differences between cases and controls are noted in response to questions about the mother's pregnancy with the index child. FTT children were not disproportionately "premature"; 86% of all mothers had deliveries which were at full term without complication. Mother-Child SeparationsSlightly more separations had been experienced by children with FTT than the control group (p < 0.08). However, no differences are observed between cases and controls on two critical dimensions: the age of the child at the first separation or the person who initiates that separation. Most separations in both groups (85%) were caused by the child's illnesses. Characteristics of ChildFTT infants are perceived by their mothers as substantially more sickly than controls (p < 0.001). Thirty-eight percent of FTT children are perceived as in poor health compared to 7% of the controls; while 64 % of controls are seen as healthy compared to only 14% of the FTT children. This variable is the strongest differentiator of the two groups in this study. There are considerably more reported child-rearing problems (feeding, sleeping, and discipline) in the families with children who fail to thrive than in the control group (52% vs. 38%, p < 0.02). This finding is mainly due to the greater number of feeding problems in this group (p < 0.005). No differences are noted for sleeping or discipline problems. The extent of immunization is similar in both groups. Maternal StressAlthough no single historical stress variable distinguishes between the mothers of FTT and control children, a composite measure of stress in the childhood, including frequent family mobility, a broken home, and family illness did moderately distinguish the two groups (p < 0.10). Contemporaneous stress on the mother does not differentiate the two groups. There are no significant differences on maternal perceptions of financial, legal, medical, or marital problems. Neither group complains of many specific problems with their present housing; nor have they moved differentially in the past year. Family and Support SystemThere is less perceived positive support for mothers of FTT children from family and neighbors than for the control mothers. Mothers of infants who fail to thrive much more often responded that their neighborhood is unfriendly (40% vs. 9%, p < 0.002) and that they do not like their neighborhood (41 % vs. 14%, p < 0.007). Moreover, although mothers of both cases and controls indicate similar numbers of nearby relatives, mothers of infants who fail to thrive see their relatives less often (33% vs. 12%, p < 0.019). FTT families also have slightly more homes without a telephone (p < 0.09). Both groups have, however, a similar degree of involvement with social service agencies. Discriminant Function AnalysisThe previous section presented variable by variable comparisons of FTT and their controls. Obviously, many of the items are highly intercorrelated. To ascertain the maximum differentiation between FTT and their controls, eliminating the variable redundancy, a discriminant function analysis was performed.
The discriminant function was determined by defining FTT families as "1" and the controls as "0." A stepwise regression was then calculated on the (1, 0) variable. The results, presented in table 3, show the significant variable in order of decreasing importance. Three variables significantly account for all the variances explained in discriminant analysis. Relative to the controls, FTT families have children with ill health, they live in an unfriendly neighborhood, and they have a larger discrepancy in parents' education. All other significant variables noted previously are subsumed (i.e., highly correlated) by these three factors. The results of the two methods of analysis are consistent. Overall, a multiple R of 0.660 is obtained.
0.249 0.099 0.035 In other words, 43.6% of the variances between the FTT and control families is accounted for by these three variables. The ill health of FTT children is, by far, the pre-eminent discriminator between the two groups. Familial and maternal factors are not strong discriminating factors. DiscussionFTT is principally a syndrome of young children. This study, similar to the case report studies (Glaser et al., 1968; Hannaway, 1970; Riley et al., 1968), saw very few FTT children over 18 months of age, with the majority being below 1 year of age. Since growth failure is rarely seen after 18 months of age, it suggests that FTT is a diagnostic label virtually restricted to infancy. Subsequent to the data collection efforts of this study, FTT has become a common discharge diagnosis for newborn infants held in the neonatal intensive care unit at Children's Hospital Medical Center. These infants could not have the same etiology as the slightly older FTT children. Future FTT studies should have a lower and upper age limit in order to obtain a more homogeneous subject population. The higher proportion of males is a striking feature of the present FTT sample. This finding is stronger, but parallels similar distributions seen in many other studies (Glaser et al., 1968; Hannaway, 1970; Pollitt et al., 1975; Riley et al., 1968). Ratios of 3:2 or 2:1 predominate. This suggests greater vulnerability for males to the determinants of FTT; it is consistent with the generally greater male morbidity and mortality vulnerability in early childhood. Since the FTT and control families were matched on an index of SES, it is difficult to explore fully the role of social class in the etiology of FTT. As could be seen in table 1, Newberger et al. (1977), found that FTT children are more predominantly white and more middle class relative to children with other pediatric social illnesses. This may be explained in our study by the fact that a large urban teaching hospital draws its nonthriving baby population from a wider catchment area than is the case for traumatic injuries or acute short-term medical illnesses. The distribution of social class in present FTT families, using the Hollingshead (1965) two-factor index of social position, parallels or is even a bit higher than the distribution found in the New Haven area (Hollingshead and Redlich, 1958). The percent of families in social classes I to V, highest to lowest, for present FTT families is 0%, 19%, 17%, 45%, 19% vs. 3%, 8%, 20%, 50%, 18% in typical urban families. FTT cuts across all social classes; it does not appear to be a phenomenon directly related to poverty. Two major ecological realities distinguished the FTT families from their controls: the characterization of the FTT children as problematic and sickly and the lack of a supportive familial and neighborhood environment. FTT children are perceived by their mothers as very sickly. Clinically, these are not active, robust children. Exactly how sick the children actually are, however, was difficult to assess, as the amount and quantity of medical intervention prior to the present hospitalization could not be systematically ascertained. Nonetheless, these children are objectively physically smaller and have more infant-parent separations due to their illnesses. To most mothers, many hospitalizations means they have a sickly infant. The FTT children also present their mothers with more child-rearing problems. Not surprisingly, these problems mostly center around feeding. This observation is also noted in more detail by Pollitt and Eicher (1976), who directly examined the behavior of 18 FTT children and their controls. They report that the failure to thrive children had more feeding difficulties as infants, had skimpier and less regular meals, had poorer response to food, and had a lower daily calorie intake. Over 50% of their mothers reported having difficulties feeding them during the first twelve months. Clearly, the FTT children are experienced as markedly different from the control children. Perhaps, it is the characteristics of the child which cause the mother's perceptions and not vice-versa. The direct role of the child in the etiology of FTT must be more seriously considered. Pollitt (1973) has shown, in a fine review paper, that the infant's physical and social characteristics often directly contribute to his own malnutrition. Rosenn et al. (1980) point out that many parents of children who fail to thrive hear the word failure-their failure-as the key word in the medical diagnosis. Is the anxiety, depression, and overprotectiveness of the FTT mother that is so frequently observed in clinical practice the cause or the effect of the child's growth failure? The lack of positive contact with neighbors and relatives seen in the FTT families is not necessarily a negative reflection on the mother's personality. Indeed, it may be the consequence of society's response to a family with a chronically ill infant. If one has a sickly child, would one want to show it off to friends and relatives? And what kind of feedback would one receive? This psychological isolation from neighbors and relatives might be further exacerbated by the fact that the mothers of FTT children have much less education relative to their husbands. This suggests the possibility of different parental expectations within the immediate family itself, perhaps making the mother more isolated and ambivalent about her own role as a mother. Demographic, poverty, pregnancy, and contemporaneous stress factors did not differentiate FTT families from their controls. Environmental stresses on the mothers of FTT children do not appear to be so overwhelming that they would be unable to give proper attention to their child. One can also conclude that FTT is not simply due to maternal youth or inexperience, since FTT mothers were not younger than non-FTT mothers, nor were FTT children predominantly first born children. Reports of high maternal rejection of their FTT offspring (Maginnis et al., 1967) have appeared in the literature. These are consistent with the surprisingly high percentage of all women (36%) in this study who reported they did not initially want their child. However, neither this factor, nor any pregnancy measure distinguished FTT from its control group. Thus, many areas of non-psychiatric maternal variability, which might have been suggestive of a maternal etiology for FTT, did not prove to be significant. Although this study incorporates important methodologic improvements over most prior FTT research in its use of a well-matched control sample and a systematic examination of familial characteristics, the results must be viewed tentatively. First, this study's FTT sample may be somewhat biased toward more ill children, as they are drawn from a large urban referral hospital. Community based hospitals may see more FTT cases associated with maternal negligence and less with medical needs. Second, the results of this and most other prior FTT studies may be obscuring some FTT patterns by considering all FTT cases together. There may be several distinct subgroups within the larger FTT diagnosis. Third, the interview instrument itself served to limit this study. The standardized interview which covers a wide range of familial conditions was originally prepared for use in a larger study of social pediatric illnesses (Newberger et aI., 1977). In retrospect, it is clear that several topics of special importance to FTT need to have been explored in greater depth. In particular, information related to nutritional knowledge and behavior was inadequate. Birth outcomes, social isolation, and perception of infants also should be explored more fully in subsequent studies. Since most of the literature assumes a maternal causation for FTT, much of this paper's discussion of the data focused around this topic. Maternal causation could take many different routes; several were explored in this study; e.g., maternal inexperience, poverty, mother-child separations, etc. This study is, however, limited in its ability to assert that maternal psychopathology or interactional behavior is or is not the cause of FTT. This study did not directly examine or observe these issues. In general the results were not supportive of a maternal etiologic orientation, but this critical hypothesis still begs further directed research. Summary and ConclusionsThe familial characteristics of young children who are failing to thrive were explored through structured interviews with mothers of 42 FTT children and 42 matched controls. Three factors distinguished the FTT families from the controls. They had a more sickly child, were more isolated from neighborhood and family support, and had a larger discrepancy in parents' education. Demographic, pregnancy, poverty and contemporaneous stress factors were not significant. A clearer picture of the familial context of FTT is emerging. In particular, this study suggests that the widely held assumption that maternal behavior is the primary cause of FTT needs reexamination. More attention should be paid to the contribution of the sickly child to the diagnosis of FTT. Such a child could contribute to the maternal psychological distress and disrupted mother-child interaction patterns seen in clinical practice. Maternal behavior may be the consequence, not the cause, of FTT. The simple assertion of inadequate mothering does not help us to understand nor to provide better care for these children and their families. ReferencesAinsworth, M. (1969), Object relations, dependency, and attachment:
a theoretical review of the infant-mother relationship. Child Develpm.,
40:969-1025.
Dr. Kotelchuck is Assistant Professor of Social Medicine and Health
Policy, Harvard Medical School, and Research Associate at Childeren's
Hospital Medical Center. Dr. Newberger is Assistant Professor of Pedriatics,
Harvard Medical School and Director of Family Development Study, Children's
Hostpital Medical Center. This study was supported by a grant (CB-141)
from the Office of Child Development Study, Department of Health Education
and Welfare. |
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