Background to the Research

• In 1977 an in-depth study of non-organic failure-to-thrive children and two control groups began. There were two major objectives guiding the study: first, to identify possible causal factors of NOFTT; and second, to develop and to test the short-term and long-term effectiveness of treatment and intervention strategies for this client group.
• The findings of the original investigation of this controlled study and the effectiveness of the data were published at the five year follow-up stage. The NOFTT and additional 27 cases referred between 1978 and 1979 for assessment and treatment have been followed up in the same way until 1998. Thirty-one out of the possible 44 cases were available at the final follow-up. The aim of the long-term follow-up was to find out what happened to those children over the intervening 20 years, and whether early failure-to-thrive negatively affected them physically, emotionally, socially and educationally in the long run.

Research Approach

• The sample comprised 31. There were 16 males and 15 females ranging in age from 20 to 28, with a mean age of 21.6. Semi-structured and open-ended interviews took place with adults who had failed to thrive when young. Whenever possible, parents, adopters or foster carers were interviewed too. Respondents were asked about what had happened in the years since initial investigation; whether early problems had lasting effects on the subjects' lives and functioning, and how helpful or effective intervention had been.
• The results presented in this chapter are mostly based on qualitative data, however quantitative methods were also used to obtain demographic and growth data. Validated questionnaires were used to assess attachment and sense of well-being.

Main Findings

Long-term Outcomes

• The most striking features to emerge from this study were the correlations between the age of child at referral point, time of catch-up in weight and height, improvement in mother-child relationship, and long-term outcomes. Children who were referred for medical investigation and psychosocial assessment and intervention during the first year of life (55%) and who made satisfactory progress have done well on both a short and long-term basis. Significant positive results were identified in relation to physical growth, cognitive development, educational attainment, psychosocial stability and maturity, secure attachment to partners and other significant people, and a sense of well-being generally.
• On the other hand, children with a long history of failure-to-thrive (45%) referred for assessment between 3 and 7 years of age, and whose improvement was slow or unsatisfactory if they remained at home, had disappointing outcomes. This was especially apparent with respect to height, educational attainment, cognition, employment, social adjustment, emotional stability, attachment and a sense of well-being. These 15 subjects were classified as psychosocial short stature, 8 falling into the hyperphagic group (overeaters) and 7 into the anorexic group.
• Six out of the latter 15 were removed from neglectful and abusive homes and achieved better outcomes than the 9 remaining at home. Two subjects who were adopted at 3 and 5 years respectively have done well both professionally and personally. Children who were fostered (3) at the age of 4, 5 and 7 had poorer educational achievements and employment, as did one subject who was accommodated with his father at the age of 11.
• Nine out of 15 who remained at home (3 on the Risk Register) developed behavioural and emotional problems such as delinquent behaviour, running away from home, aggression, inability to concentrate, and disruptive and attention seeking behaviour. Seven of them were statemented for special education.
• Six subjects had, on average, 3 to 4 episodes of respite foster care. During their stays with foster parents growth and development diminished but resumed and worsened on return to their homes.
• Psychosocial subjects reported being badly treated as children by their mothers or siblings and felt that they had better relationships with their fathers. The marital relationships of FTT children's parents in three quarters of the cases was problematic, marked by more serious frictions and quarrels in almost half of the sample. Marital breakdown took place in 7 families between the closure of the case and the final follow-up.

Self-confidence and self-esteem

• Fifty per cent of respondents felt positive about themselves in terms of their achievements at school, higher education and work. They were also satisfied with the relationships within their families during childhood and adolescence and current contacts with parents and siblings. Their sense of belonging was deeply rooted in their parental home. They found it easy to form romantic and friendly relationships and were able to deal with conflicts, disagreements or difficulties with relationships in an assertive and confident manner. They were securely attached to partners and in 7 cases to their children.
• Thirty per cent reported a lack of self-confidence when dealing with other people. They were often bullied at school, and found it difficult to assert themselves at work and or in their personal relationships. They tended to give up an idea or request easily and to their disadvantage, even when they had the power or were in a position to protect interests and rights. They were often manipulated, undermined and used, and although they were aware what was happening, were unable to stand up for themselves. These subjects associated their difficulties with their experiences as children and the way they were treated by their parents, siblings, peers or teachers.

Relationships with significant people

• Thirty-five per cent reported often feeling insecure in their relationships with partners, friends or parents. One in five tended to be aggressive and pushy in order to hide their internal fear and apprehensions.
• The current relationship with parents has been described as good or much better than it was in childhood in 68% of 31 cases. This was true for siblings in 55% of cases. In the cases where early relationships were problematic the situation seemed to change when they left home or became parents themselves. There were some totally unpredictable outcomes in 2 cases. Both subjects were severely rejected by mothers, resulting in serious behavioural and emotional problems.
• The results are not so optimistic for those subjects classified as psychosocial short stature and referred after prolonged difficulties at home. Ten out of 15 subjects continue to have poor relationships and contacts not only with parents but with siblings as well. Lingering indifference, alienation and detachment is apparent and appears to be insurmountable. This is particularly the case for those who were fostered out compared to those who were adopted.

Physical growth, psychosocial and educational attachments

• At the time of follow-up, 19 subjects are slightly smaller than their siblings or parents. Most subjects managed to achieve average height and weight and were able to catch up in terms of physical growth.
• Twenty subjects appear to have appropriate weight for height, and look well. Nine are underweight for their height, while 2 are exceptionally thin and 2 are obese.

Eating behaviour

• Currently there are no very serious eating problems. One subject became anorexic at 16 but reports that after 2 years of treatment she recovered and is now fine.
• Seven tend to eat a lot when under stress and 2 consume large quantities of food. Four lose appetite when stressed. Eating behaviour appears to be determined by mood rather than hunger and good appetite or eating needs and routines of eating.

Education and employment

• Intellectual cognitive ability appeared to be appeared to be impaired in 40% of the cases. School attainments in those cases were poor or very poor. Six subjects had not passed any exams such as GCSEs; 7 were moved to special education due to their slowness in learning and maladjusted behaviour. Five subjects are semi-literate and four have considerable difficulties with reading and numeracy in spite of finishing secondary education.
• Difficulties with maintaining employment are apparent where the ability to read and act upon written information and instructions is necessary. Six subjects had had between seven to ten different jobs since they left school.
• Two subjects who were diagnosed as severe psychosocial short stature were adopted at the ages of 4 and 5 years respectively and have done very well personally and professionally. Both have finished higher education, are in successful jobs and have stable marital relationships, and one has a four month old baby, thriving and well cared for.

Other Findings

• One subject developed manic depression at the age of 21 and was treated in hospital for 6 months. In spite of having finished a university course, she is unable to maintain any employment. Another person was committed to care at 13, when it was discovered that the mother starved the child deliberately. This child grew quickly in a new foster home, became alert, sociable and outgoing and his school work improved vastly.
• Acute anxiety was identified in 4 subjects. These subjects were acutely rejected by their mothers and often siblings. Their attachment to primary carers was classified as insecure/anxious or avoidant.

Interviews with Subjects' Parents

• All mothers, and two thirds of fathers, were interviewed to find out how they feel now about the child and how they view the help which was available to them. Four mothers still feel angry that their worries, concerns and persistent requests for investigation to possible organic causes for FTT were not taken on board for a long time by the medical profession. Subsequently, organic causes were discovered and eliminated by surgery or medication, so that the children began to grown and their relationship with the parents improved.
• Over 60% of parents stated that their early difficulties in terms of child-rearing and their relationships have improved considerably due to the support and therapeutic help provided by the social worker/researcher and in ten cases, paediatric services.
• Provision of day nursery, family centre or daily minder was highly appreciated and identified as being very helpful.

Conclusions

• Some important messages emerged from this study. Although the sample is small, it is nevertheless suggestive and in line with earlier and shorter-term follow-up studies. Earlier identification, well devised treatment/intervention, and implementation of helping strategies in partnership with parents led to improved intake of food, weight gain and mother-child interaction. All subjects referred and dealt with during the first year of life managed to escape adverse consequences, in contrast to those who came to professional attention after prolonged difficulties.
• Optimistic expectations that problems would disappear without serious consequences and reluctance to take appropriate action when FTT persisted were too often apparent amongst all professions involve with FTT children. FTT can have serious and long-lasting consequences as outlined in this summary, but equally it can be resolved quickly and effectively if attended to seriously at the onset of the presenting problems. Early identification of poor weight gain, withdrawn and detached behaviour, inadequate food intake and problematic mother-child relationships should inform professionals that they need to step in so as to prevent further harm.