Environmental failure to thrive: a clinical view

Psychometric properties of the Chinese version thriving of older people assessment scale

BACKGROUND

The Thriving of Older People Assessment Scale has Scandinavian, Norwegian and English versions but does not yet have a Chinese version that can be used in Chinese populations and compared to global data.

OBJECTIVES

To evaluate the psychometric properties of the translated Chinese version of the Thriving of Older People Assessment Scale.

METHODS

The English version of the Thriving of Older People Assessment Scale was translated into Chinese using a forward and backward translation method. A convenience sampling strategy was used to recruit participants from five long-term care facilities in northern Taiwan (N = 285). Confirmatory factor analysis was then performed to confirm the theory of the Thriving of Older People Assessment Scale Chinese version.

RESULTS

The Thriving of Older People Assessment Scale Chinese version consists of 32 items loading across five domains, namely, 'resident attitudes towards being in long-term care', 'quality of care and caregivers', 'resident engagement and peer relationships', 'keeping in touch with people and places' and 'quality of the physical environment', with good internal consistency (0.971). Confirmatory factor analysis results showed that χ² = 2255.58 (df = 459, p < .00), χ² /df = 4.91, CFI = 0.96, IFI = 0.96, NNFI = 0.96 and SRMR = 0.074, indicating a good model fit to previous factor structures.

CONCLUSIONS

The Thriving of Older People Assessment Scale Chinese version is a tentatively reliable and valid tool for measuring the experience of thriving in Chinese language older people in long-term care facilities.

IMPLICATIONS FOR PRACTICE

The Chinese version of Thriving of Older people Assessment scale can be used to describe the levels of place-related well-being among older Chinese people living in long-term care. Further research and improvements of the Thriving of Older People Assessment Scale Chinese version in diversified Chinese contexts will enable a more comprehensive understanding of older Chinese people's experiences of thriving in long-term care.

Preventing Rickets in Locally Appropriate Ways: A Case Report from North China

A rickets prevention program was carried out in Shanxi Province, China using locally appropriate methods. At the end of two and one-half years, the prevalence of rickets was 18% lower in program townships (56%) than in a control township that had no rickets prevention program (74%). Maternal awareness of how to prevent rickets was higher in program townships (43%) than in the control township (28%). However, the actual effect of maternal awareness on the prevention of rickets was negligible. In conclusion, this rickets prevention program was effective at reducing the prevalence of rickets. It appears the program was effective because of the presence of concerned program workers regularly visiting mothers and their infants, and using locally appropriate methods, but neither the vitamin supplements used nor the kind of rickets prevention education provided the mothers was shown to be positively correlated.

Nonorganic failure to thrive: a theoretical approach

Nonorganic failure to thrive (NOFTT) is a significant health problem of infancy. Although NOFTT is thought to be a result of multiple factors, exactly what these factors are is unclear. Explaining the development of NOFTT has been hindered by a lack of a theoretical approach. The purpose of this article is to provide a review of the literature and the discussion of a theoretical framework to guide future research in the area of NOFTT.

Nutritional management of failure to thrive

Failure to thrive, or failure to grow or gain weight, could have several causes that are reviewed in this article. Infant behaviors are discussed, together with nutritional management, catch-up growth, effects of nutritional rehabilitation on body composition, follow-up, and long-term prognosis.

Functional vomiting disorders in infancy: innocent vomiting, nervous vomiting, and infant rumination syndrome

Pediatric gastroenterologists have tended to view gastroesophageal reflux (GER) as a disease in and of itself--a disease that can be diagnosed "objectively" with use of numerical data from esophageal pH monitoring and cured with pharmacologic or surgical treatment. What is often forgotten is that the data derived from esophageal pH monitoring and other techniques may identify the presence of abnormal GER but tell nothing about its pathogenesis. The usual approach to infants who feed poorly, vomit, or fail to gain weight is to identify the presence of abnormal GER, rule out underlying organic causes of vomiting, and then diagnosis primary GER disease. The baby is then treated with pharmacologic, dietary, or positional therapy and, ultimately, if these therapies fail to eradicate the symptoms attributed to GER, surgical fundoplication, which stops vomiting regardless of its causes. The pediatric literature on infant vomiting and GER is almost devoid of research into the nature and possible relationships among infant stress, vomiting, feeding difficulties, and failure to grow. Clinically, the quality of the maternal-infant relationship is frequently approached superficially, with psychosocial aspects treated as less important in infants considered to have primary organic disease amenable to medical or surgical treatment. Psychosocial factors in the pathogenesis of the infant's symptoms are often not pursued beyond assessment for possible abuse or neglect. It has been known for centuries that stress or excitement affects gastrointestinal function and symptoms. Although the field of infant psychiatry has produced a substantial literature on the nature of stresses that affect both infants and mothers, the pediatric literature on vomiting and failure to thrive seldom acknowledges the existence or importance of these contributions. In clinical practice, failure to explore psychosocial aspects that may contribute to vomiting, feeding difficulties, or failure to thrive may result in missed opportunities for less invasive, more effective therapy at best, and countertherapeutic treatment at worst. This article describes three functional vomiting disorders of infancy, their distinguishing characteristics, hypotheses regarding their pathogenesis, and principles of comprehensive management.

Behavioral treatment of child neglect

Child neglect is a serious and prevalent problem. It is often chronic, and parents accused of child neglect may refuse treatment or may fail to cooperate fully. Described here are some examples of empirically evaluated treatments for child neglect dealing with hygiene, nutrition, home safety, and cleanliness, affective skills training, infant stimulation, and teaching health-related skills. Also discussed is a concern for a need for primary prevention programs.

Failure to thrive

Malnutrition is the primary biologic insult in most cases of failure to thrive. A transactional model of infant development provides a framework for understanding the psychosocial context in which such malnutrition occurs. Each child who fails to thrive should receive a multidisciplinary evaluation to address the diagnostic and therapeutic implications of nutritional, medical, psychosocial, and developmental factors contributing to growth failure.

Children of mentally ill mothers: mental development, somatic growth and social outcome

A two-year cohort of children of parapartum mentally ill mothers born in Stockholm during the mid-70s was studied with regard to mental development, somatic growth and social outcome. The observation period covered the pre-school-age period and the study was based on Well-Baby-Clinic (WBC) data. The findings were compared with those of matched controls. Nearly 40% of the children of the mentally ill mothers, compared to 3% of the controls, did not live with their biological mothers during the pre-school ages. No difference was found in somatic growth between the index and control children. However, more index children--especially those of addicts and neurotic or temporarily insufficient mothers--than controls suffered from developmental (p less than 0.05) and behavioural (p less than 0.001) disturbances. Fifteen per cent of the index children compared to 5% of the controls were judged by the staff of the WBC to be in need of treatment for psychological problems (p less than 0.01). The results of the present study emphasize the fact that children of mentally ill mothers constitute a high-risk group regarding mental and behavioural development. The study supports earlier research reports claiming that, while parental mental illness constitutes an important indicator of psychiatric risk for the children, the main risk stems from associated psychosocial disturbances in the family.

Somatic manifestations in children suspected of having been maltreated

The present study revealed an incidence of maltreatment of 26.8 in 100,000 children under 15 years of age, higher than previously assumed. The sample comprises 41 children suspected of having been maltreated. A systematic examination included radiography and isotope scintigraphy of the skeletal system. In 9 cases the diagnosis was not confirmed, in 23 confirmed, and in 9 children it seemed likely. The most common form of maltreatment was physical violence with bruises. A total of 6 fractures were demonstrated. Three children had been exposed to sexual abuse. Intracranial haematoma, of long standing, was found in one child. Thirteen of the children (40%) were of short statute, their height and weight below the 25th percentile. Among 27 children examined by X-rays 16 (59%) had delayed skeletal maturation. Disturbances of growth, as well as behavioural abnormalities, were particularly striking in this group of patients. The findings suggest that even the slightest suspicion of maltreatment should lead to a general medical evaluation without delay.

Assessment and modification of home cleanliness among families adjudicated for child neglect

Severely neglectful home environments pose threats to children's cognitive, emotional, and physical health. This research was designed to quantify and modify the conditions of the homes of three families adjudicated for child neglect. A valid and reliable measurement device (The CLEAN-Checklist for Living Environments to Assess Neglect) was used to document changes in home conditions. Behavioral techniques including feedback, shaping, and positive reinforcement were effective in improving home conditions.

Growth retardation and developmental delay amongst inner-city children

A whole population survey of an inner-city health district (population 130,000) was undertaken in order to study the association between social deprivation and non-organic growth delay in preschool children. Potential cases were identified from health clinic records. Cases comprised white, full-term singletons, whose weight and height lay below the tenth centile at 4 years of age. Allowance was made for parental stature. A comparison group was closely matched for socio-economic conditions, and other salient variables. Case children were comparatively significantly delayed in all areas of their cognitive development. One-third were seriously retarded and likely to require special education.

Prospective study of antecedents for nonorganic failure to thrive

The cause of nonorganic failure to thrive (NFT) was studied prospectively in 274 low-income pregnant mothers by interviewing them for characteristics that retrospective studies indicated were associated with child maltreatment. After delivery, medical charts of mothers and infants were reviewed for complications of pregnancy, delivery, and postdelivery hospitalization, and the infants were observed for growth failure. The characteristics of 15 families with infants who developed NFT were compared with those of 86 selected randomly from the remaining families. Interview results suggest that NFT correlates significantly with aberrant nurture during the mother's childhood and with conflicts between the parents of the infants. Perinatal events correlating significantly with NFT include complications of pregnancy, short gestation, and residual minor medical problems at discharge from the nursery. We speculate that these events predispose to NFT by disturbing the development of the mother-infant relationship.

Non-organic failure to thrive

Non-organic failure to thrive is a clinical diagnosis which should be considered in parallel with other causes of failure to thrive in infants. It has not been resolved as to whether the condition is due to a lack of stimulation or to deprivation of calories, although both these factors, as well as a contribution from the child in some cases, are likely to be responsible. There is no typical profile of the parent whose child develops non-organic failure to thrive. The condition can occur in all social classes but is more common in situations of poverty, poor marital relationships, chaotic family lifestyle and when there is a history of deprivation in the parents' own childhood. Although the majority of these children eventually show catch-up growth, long-term follow-up studies show a high incidence of emotional and cognitive problems. Treatment should go beyond nutritional rehabilitation in the hospital and should include practical, supportive help for the mother together with measures to improve the level of stimulation and the quality of interpersonal relationships for the child.

The families of children who fail to thrive: preliminary investigations of parental deprivation among organic and non-organic cases

A majority of cases of failure to thrive (FTT) do not have a known organic etiology. Social and psychological determinants are sought for these "non-organic failure to thrive" (N-O FTT) cases. Social and psychological differences between non-organic and organic cases are also explored here. With the introduction of the term, "maternal deprivation," medical practitioners have implicated mothers' deficiencies as instrumental in the etiology of N-O FTT. However, these mothers are themselves usually deprived. Lack of cooperation in childcare by both parents is noted when classic clinical cases are reviewed. We suggest that the concept, "parental deprivation," provides a more accurate model. Preliminary research findings support our hypothesis that mothers of FTT infants do not have good social support networks. Teen motherhood and socioeconomic status also appear to be important, but not necessary as determinants. An unexpected finding is that there are few differences in the social deficiencies of families of N-O FTT infants as compared to those failing for organic reasons. Two unanticipated findings appear noteworthy. First, infants failing for organic reasons are significantly smaller and thinner at birth, independent of pregnancy complications or prematurity. Second, infants failing for non-organic reasons are more likely to present during the period of infant-caretaker role development and less likely in the later toddler stage. Additional research into the feasibility of strengthening family supports as a basis of intervention is recommended.

Growth of intelligence: failure and catch-up associated respectively with abuse and rescue in the syndrome of abuse dwarfism

IQ change in association with change of environment occurred in a sample of 34 patients with a diagnosis of abuse dwarfism. Low and persistent impairment of IQ was associated with abuse. By contrast, IQ elevation was associated with rescue. Multiple regression analysis revealed that duration of rescue was the primary variable associated with IQ elevation; age and IQ level at rescue were secondary. IQ elevation was gradual and progressive over the years, as rescue was maintained. In abuse, the mean IQ was 66 (range, 36-101), and after rescue it was 90 (range 48-133). The greatest magnitude of change, from IQ 36 to 120, was in a girl between the ages of 3 yr 8 months and 13 yr 11 months.

Health of children whose parents seek psychiatric care

The study comprises 69 pre-school children whose parents, mainly mothers, had sought care at a department of psychiatry in Stockholm. The majority of the parents had attended for recurrent ambulatory treatment (58%) or had only come to the emergency room (25%). The children demonstrated a significantly higher frequency of somatic and emotional symptoms than a matched control group. To a large extent, the index children showed failure to thrive without any apparent organic cause. In exceptional cases there had been co-operation between the departments of psychiatry and paediatrics (one case) as well as between the departments of psychiatry and social welfare (five cases). There is an urgent need to develop methods within the scope of psychiatric care whereby the best interests of both the parents and the children are taken into consideration.

Failure to thrive

Reviewing the chronological evolution of our understanding of why some children fail to thrive without obvious organic cause permits us to develop a rational contemporary approach to diagnosis and management. Originally recognized as a phenomenon of children living in institutions, it later became clear that it could occur in children living with their families. While emotional deprivation was at first emphasized as the principal determinant of growth failure, it is now apparent that the major mediating mechanism is insufficient caloric intake. Thus prior to nutritional recovery it may be difficult to segregate whether emotional symptoms in the child reflect the causes or effects of malnutrition. With rare exceptions, an etiologic diagnosis can be suspected on the basis of history, physical examination, and family assessment. Nonspecific investigative screening of such children has proved to be without value. Successful management depends on recognition of the supernormal caloric intake required to induce rapid catch-up growth. Aggressive hyperalimentation combined with intensive emotional stimulation and often with active family participation offer the best chances of a successful outcome.

Failure to thrive

Failure to thrive is one of the most common diagnostic problems in pediatrics. The term is applied to describe a still poorly defined entity. We will define failure to thrive, review the frequency of various etiologies, and present a logical approach to this problem.

Diagnostic value of a psychological test in cases of suspected child abuse

The use of the Bene-Anthony Family Relations Test is described and illustrated by three examples of child abuse. This test should be considered in the investigation of definite or suspected cases of abuse and as part of the preparation of court evidence.

Radiographic findings in children with psychosocial dwarfism

The diagnosis of psychosocial dwarfism is established through history, the determination of delay in growth and skeletal maturation, the lack of evidence of organic disease and accelerated growth and psychomotor development in a nuturing environment. Radiographically temporary widening of the cranial sutures may be detected in a follow up examination or less often already at the time of initial examination. Determination of wide cranial sutures may be contributary in establishing the diagnosis of psychosocial dwarfism. In a patient with this syndrome and lack of neurological signs or symptoms widening of the cranial sutures is an expected finding and no further neuroradiologic studies are necessary.

Failure to thrive and anorexia nervosa

A case study is reported of an anorexia nervosa mother who battered her elder male child (‘battered baby’) and in collusion with her psychopathic husband starved to death her 10-week-old daughter. The association of anorexia nervosa in the mother with death by starvation has not previously been reported in the literature. The possible underlying psychopathology is briefly discussed.

Failure to thrive--a retrospective profile

"This paper presents the incidence of growth failure in 44 patients for which no organic cause was discovered after investi gation. This group of patients, collectively termed failure-to-thrive, represents the sec ond largest diagnostic category of patients with growth failure admitted to a children's hospital in one year. An examination of various features of this group from a review of the medical and psychosocial histories is made and changes in growth patterns in hos pitalization and follow up are documented."