Attachment & Family Relationships DTW

Key Points

• A primary task of the first year of life is the development of the child's attachment to a caregiver
• Attachment occurs in stages: infants under 3 months demonstrate the ability to discriminate between familiar and unfamiliar people; Infants 7-9 months demonstrate a clear preference for one or a few people; At 8 months, stranger anxiety and/or distress emerge; Toddlers 15-24 months show renewed "clinginess"
• During the first year, infants practice independence but need trusted adults as a secure base of support
• Quality of parent-infant attachment comes in part from how the parent responds to the infant (Ainsworth, M.D.S. 1978) . An infant whose needs are generally responded to promptly and contingently will likely develop a sense of confidence in herself and her parent, called a secure attachment. Babies in secure attachment relationships are more readily able to seek, derive comfort from, and settle based on contact with caregivers during periods of stress, such as after separations. In contrast, an infant whose needs are met inconsistently may develop the sense that the world is not a trustworthy place, and demonstrate a pattern of insecure attachment. Babies in insecure attachment relationships typically appear less capable of deriving support from caregivers during times of stress. For example, babies may appear to 'ignore' caregivers' overtures or may remain fussy, inconsolable, and ambivalent during contact with caregivers. In problematic but still normal cases, infants with insecure attachment relationships have been shown to be less autonomous and less positive in social interactions during the preschool years. In disordered cases, infants may become disorganized when stressed (Main, M. 1990) , or may show indiscriminate attachment (Zeanah, C.H. 1993) . In such cases, infants appear to have difficulty relying on a parent for support in a consistent, organized way. These difficulties are associated with later risk of behavioral/emotional disturbance.
• Many factors influence a parent's ability to be sensitive and responsive to an infant. These include: misconceptions about young children's needs, medical or mental illness, stress or work-related issues, substance use , parents' abilities to be open to attachments (usually based on experiences with their own parents) (See Insecure Attachment PT; and temperamental differences between parent and child (See Helping Create a Better "Fit" Between Parent and Child).

Latest Research on Attachment Disorders

Management

• Observe the quality of infant/parent interaction: Consider using the sensitivity rating scale (link). Does the parent notice the infant's smiles, frowns, reaches, and bids for attention? Does he/she respond appropriately (e.g. smiling back)? What is the parent's response to the infant's cries?
• Help parents who have difficulty reading infant cues: When instances of significant "mismatch" are noted (e.g. multiple child cues that appear to go unnoticed by the parent), make an effort to point out child cues to the parent ("Look at that big smile!"). (Reading baby's cues PT)
• Help parents manage phases in which infant demands exclusive care of one parent: In many cases (particularly around 8-12 months and again during the early toddler months) infants may go through periods in which they demand the exclusive care of one parent (in most cases the mother). Help fathers to understand this "rejection" as an expected stage of development. Coach mothers to comfort promptly but then pass the baby to him and move out of sight to give dad a chance.
• Consider factors that may influence attachment quality: Does the infant have a difficult temperament (See What Kind of Temperament Does My Baby Have? PT) that may make it challenging for the parent to be warm and responsive? If so, offer support in fostering "goodness-of-fit" (See Helping Create a Better "Fit" Between Parent and Child). In cases where parent factors such as depression (See Parent Depression PT), substance use , or life stress (See Parent Work/Stress PT) may be inhibiting the formation of a secure attachment, provide information and referrals to the parent as appropriate.
• Managing separations: Help parents understand the child's behavior and how their actions and reactions affect it. For many parents a child's separation is very painful and they show their own pain. They may also have difficulty setting consistent limits (See Principles of Limit setting PT) as the child begins to explore or to protest separation, which may confuse her.
• Assist parents in fostering secure attachments. Special cases include the following (adapted from Bright Futures in Practice, Mental Health)
• The prenatal period: Prenatal discussion might include questions such as How has the pregnancy been going? Do you know if it's a boy or a girl? How do you feel about that? Many people have fears or dreams during pregnancy, how about you? What makes you the most anxious about your pregnancy? What do you imagine your baby will be like? What do you imagine you will be like as a parent? What parts of parenting would you like to do the same as your parents? Differently? What are the plans for delivery: father's role or other support for mother? What are your plans for feeding the baby? How does your partner feel about that? What will the new baby's arrival mean to your lives? How will it affect your relationships? How do the other children in the family feel about this baby coming? How will it affect your participation in activities/employment? Who will be available for support when the baby comes home? What does this baby mean to your family?
• Newborns:
• Foster the development of nurturing behaviors and understanding of infant cues in the hospital by encouraging early contact and rooming in, helping parents read infant cues, and ensuring that parents are comfortable with feeding .
• Help parents read infant cues, especially with premature babies who may be less organized in the cues they give.
• Educate parents on Engaging cues (turns toward parent, reaches up, opens eyes); Disengaging cues (turns head away, falls asleep, signaling need for less stimulation); Hungry cues (fusses, mouths fists, makes sucking noises, turns to parent with flexed posture); Full cues (falls asleep while feeding, sucks less vigorously, relaxes & extends arms and legs).
• Facilitate parents' discovery of methods to soothe their baby (wrapping baby so fingers are accessible for sucking, soothing baby with soft voice, repetitive touch or movement). Advocate use of soft infant carriers to maximize physical contact with baby.
• Demonstrate infant abilities in the newborn period, especially locking gaze, tracking visually, and turning to the parent's voice. These all make the newborn seem more human and "theirs".
• Help parents with the transition home by ensuring that basic food/shelter/safety needs are met as well as encouraging them to use family, friends and the health care team for support as needed.
• Help parents anticipate periods of feeling tired or "blue". If the feelings are intense or persistent, refer as indicated to support persons and/or mental health providers (See Parent Depression PT).
• Encourage parents to rest when infant is resting. Suggest that the father protect the mother's rest and that friends and relatives be given household chores when they offer to help.
• Be open to ambivalent feelings and accept them. Encourage partners to accept each other's rate of attaching to the baby. The typical time at which parents experience "love" for the newborn is 6 weeks, not at birth.
• Discuss the fact that bonding happens even in cases of severe illness or separation of mother and newborn and in adoption. Adverse delivery circumstances have many side effects but an altered parent-child relationship does not have to be one of them. Parents are often worried about this perhaps reflecting subtle disappointment in their baby or the delivery circumstances.
• Older babies:
• Help parents see their role in promoting a secure attachment. Help them understand the messages they give their child through responses and facial expressions. Try to understand the feelings behind these messages, especially ones that relate to difficult memories or sad feelings.
• Point out a child's social milestones to parents in order to help them appreciate their child's growing attachment to them. Suggested milestones are as follows: Newborn (scans the parent's face); 6 weeks (beginning to smile and coo interactively); 4 months (child learns about others/beginning of stranger awareness); 7 months (growing awareness of strangers, stranger anxiety); 9 months (ability to remember when parent is absent; separation anxiety; turns to care provider after exploring or when in distress). Help parents develop methods that facilitate these social milestones. For instance a parent can show approval and verbally reassure when a 5 month old child looks at a stranger and then back to the parent or can prepare a 9 month old for separation rather then increasing his anxiety by leaving without notice.
• Help parents understand the value of a transitional object (lovie) as an extension of themselves. Discuss offering a teddy bear, blanket or other significant object to help their child begin to tolerate being away from parents while still maintaining an attachment to them. Help ambivalent parents to understand that the use of transitional objects is not indicative of problems in the child and instead is associated with increased independence.
• Encourage parents to accept rather than resist regressions, especially after the birth of a sibling. Allowing regression tends to speed its resolution and convey to the child that nurturing is always available to them.
• All ages:
• Certain temperaments may be harder to accept and love than others for some parents. Sometimes this is because the temperament is very different from that of the parent. (See Helping Create a Better "Fit" Between Parent and Child).
• Help parents understand irrational reactions to their child. Some parents react to the child as though s/he were someone else that they are reminded of by this child's appearance or behavior, e.g the father at whom they are now angry. Ask "Who does he take after?" to determine this. Help parents distinguish between their reaction to this other person and their own child so that they can have optimal relationships. It may be necessary to have them use a trigger to remind themselves of this difference e.g. this child has red hair therefore he is not like his father.
• If parents don't have warm feelings of attachment to this child they may need to practice playing with him or her to develop these. Suggest 10-15 minutes a day of 'special time' to play at first as an assignment. Once play becomes more comfortable warm feelings may follow.
• Look for excessive stress or depression in parents who do not seem attached to their child and refer if present.
• Preadoption Counseling : Queries might include: What has the adoption process been like for you? What do you know about the child you are about to adopt? What do you imagine your baby will be like? What do you imagine you will be like as a parent? What would you like to do the same as your parents? Differently? What will the new baby's arrival mean to your lives? How will it affect your relationships? How do the other children in the family feel about this baby coming? How will it affect your participation in activities/employment? Who will be available for support when the baby comes home? What does this baby mean to your family?
• Families with special histories (infertility, miscarriage, depression, etc.):
• Ask "How has the (infertility workup, previous miscarriage, depression, etc.) affected your anticipation and preparation for becoming new parents? "How has the (past infertility, previous miscarriage, depression, etc.) affected how you parent now? How would you like your relationship with your child to be in 5 years?
• Parents with a prior loss may need to be prescribed "grieving time" daily in separate blocks of time so that it doesn't contaminate this relationship.
• If past experiences continue to interfere with parenting, refer for counseling or a support group (e.g. Candlelighters for bereaved parents).
• Infants with special needs:
• Sensory difficulties or medical illness: Help parents recognize the infant's threshold for stimulation and signs of distress. Advise parent on additional methods of interacting (movement, touch, appropriate structure as she develops)
• Premature infants: Offer home visitation for support. Anticipate that a premature baby may not give clear cues about her needs and may often place greater demands on parents
• Adoption: Point out signs of attachment as they develop. Help parents understand that their child may need to mourn the loss of previous caregivers before attachment can fully develop. Discuss when and how parents plan to talk about adoption with the child
• Multiple births: Suggest respite care and support for parents as needed. Give attention to individual differences of each baby.
• Maltreatment: In extreme cases, children may experience caregiving deprivation, or maltreatment at the hands of caregivers. In such cases, more specialized intervention will likely be necessary :
• Infants can react to Deprivation/Maltreatment through changes in basic functions of eating and sleeping as well as irritability, clinginess and sometimes aggression such as biting.
• The main intervention for Deprivation/Maltreatment is establishing a stable daily routine with a regular kindly adult caregiver as quickly as possible.
• Multiple changes of caregivers are to be avoided as these children are already at risk for failing to have stable intimate relationships in their adult lives. Minimizing changes in caregivers may require advocacy in court by the clinician or a psychologist.
• Infant regression, e.g. wanting to be held more, refusing to hold their own bottle, or a return to night waking, should be handled by accepting the new behavior and providing prompt comfort whenever needed. After a few minutes of comforting, the infant can be encouraged to change activity or be distracted.
• Infants showing regression by renewed desire to be fed instead of feeding themselves should be fed.
• Infants awakening multiple times during the night may do better by sleeping with another person if acceptable to the caregivers. This can be weaned later when the infant is more stable.
• Infants who have been abused should have injuries and possible sexually transmitted diseases diagnosed and treated.
• When the infant has been deprived or maltreated often other adults and siblings in the family have also. This includes possible domestic violence. Their wellbeing should also be monitored and attended to in adequately caring for the infant.

Definitions

Classification of major problems related to infant-parent interaction has been done along two major dimensions. Discussion of a related phenomenon, nonorganic failure to thrive, is also provided here.

• Attachment disorders
• Relationship Disorders
• Overinvolved Type
• Underinvolved Type
• Anxious/Tense Type
• Angry/Hostile Type
• Mixed Type
• Abusive
• Nonorganic failure-to-thrive

Attachment disorders

Attachment difficulties may be manifested in infant responses to social situations. Infants in problematic attachment relationships may demonstrate any of several behaviors in interactions with significant adults: 1) lack of interest; 2) ambivalence (seeking attention, then pushing the adult away); 3) excessive fear; or 4) indiscriminance (seeking nurturance/close contact with unfamiliar adults). Attachment-related disorders are diagnosed in the context of problematic family situation, PLUS:

• Variation: Infant demonstrates any of the behaviors noted in 1-4 above, without significant effects on child/family functioning.
• Problem: Infant demonstrates any of the behaviors noted in 1-4 above, with moderate effects on child/family functioning.
• Reactive Attachment Deprivation/Maltreatment Disorder of Infancy: Infant demonstrates any of the behaviors noted in 1-4 above, in the context of either persistent parental neglect or abuse, or significant changes in parental availability (e.g. due to medical/mental illness, substance use, or major life stress).

Relationship Disorders

DC:0-3 also classifies infant-parent interaction problems along a separate axis called relationship disorders. Such diagnoses are made infrequently, based on observed parent OR child difficulties with regard to: 1) The behavioral quality of the interaction (parental sensitivity, genuineness, predictability; infant avoidance, nonresponsiveness, or defiance, as well as infant delays); 2) Affective tone between infant and parent (e.g. hostile or anxious affect from one or both); and 3) Psychological involvement between parent and infant (parental perceptions of child). Relationship Disorders for infant- parent dyads fall into distinct patterns. These are described in more detail via the links below, with key points and management suggestions included for each.

Relationship Disorders, Overinvolved Type

Parent is overprotective, controlling, and has difficulty seeing the infant in developmentally appropriate terms and as having his/her own needs and goals. Infant may be overly compliant or overly defiant, may be obstinate and "whiny." May appear delayed.

• Key Points
• Reasons for parents being overinvolved may include: Real or perceived threat (e.g. prematurity, chronic illness, past acute illness); Parental personality that doesn't tolerate mess or loss of control; Guilt over past behavior, including past abortions, angry thoughts, or day care placement; Compensation for the perceived under-involvement of the other parent; Inconsistent control due to parental anxiety, depression or anger; Lack of understanding of this baby's cues
• Reasons for inappropriate expectations may include: Lack of knowledge about normal development; Past experiences being parented themselves in this way or the opposite way; Other experiences with advanced infants; Pressure from others; Need or desire to be relieved of parenting responsibilities; Personality disorder with lack of decentering on self, e.g. borderline personality disorder
• Manifestations
1. Parent often interferes with infant's goals and desires
2. Parent dominates through overcontrol
3. Parent makes developmentally inappropriate demands
4. Infant may appear diffuse, unfocused and undifferentiated
5. Infant may display submissive, overly compliant behaviors or, conversely, defiant behaviors
6. Infant may evidence lack of motor skills and/or language expressiveness
7. Parent may have periods of anxiety, depression, or anger which result in lack of consistency
8. Infant may passively or actively express anger/obstinacy and whine
9. Parent may perceive the infant as a partner or peer or may romanticize or eroticize the infant
10. Parent does not see the infant as a separate individual with his or her own needs, e.g. attempting to involve the infant in meeting parent's own needs, using infant as a confidante, extreme physical closeness or eroticized touch, low level of reciprocity or dialogue.
• Variation: dyad demonstrates any one from items 1-3 or 9-10 above, with no significant effects on child/family functioning.
• Problem: dyad demonstrates any one from items 1-3 or 9-10 above, plus any one from items 4-8, with moderate effects on infant/family functioning.
• Relationship Disorder, Overinvolved Type: dyad demonstrates any one from items 1-3 or 9-10 above, plus any two from items 4-8, with significant effects on infant/family functioning.
• Trigger Questions: What is the hardest part of taking care of this baby? Do you have much trouble knowing what he wants? Was this your first pregnancy? Have you ever had any miscarriages or abortions? How do you think those experiences influence how you parent now? What kind of experience did you have with children before you had your own? How would your parent have handled things when you were growing up? What did you decide about that? What thoughts have you had about this behavior? When have you felt this way before sometime in your life? What have others told you to do about this baby? Are you a person who worries about all kinds of different things or just about this baby? Are there other worriers in your family?
• Management depends on etiology:
• Inappropriate expectations for age of child: Parenting classes, parent groups, playground observation, readings
• Personality that doesn't tolerate messes, etc: Discussion of effects of over control
• Past history of loss or perceived threat: Above interview, Counseling,
• Mood or personality disorder in parent: Refer for therapy/intervention
• Reaction to own past parenting: Discussion of parenting reflexes, setting own goals, noting triggers to reflex behaviors to begin stopping them,
• Influence of others: Setting own goals, parent group
• Child difficult to read: Parent-child coaching sessions, early intervention

Relationship Disorders, Underinvolved Type

Parent is insensitive to infant cues, may ignore/reject the infant; relationship may appear disengaged, flat, lifeless. Infant may appear un-cared for and delayed.

• Key Points
• Reasons for parents being underinvolved may include: Depression; Being overwhelmed by other responsibilities; Past experiences being parented themselves in this way or the opposite way; Unwanted, unplanned child; Projection onto child of hostility towards someone else; Rejection of abnormal child; Lack of understanding of needs of infants
• Manifestations
1. Parent is insensitive or unresponsive to infant's cues
2. Lack of consistency between parent's expressed attitudes and quality of actual interactions, or lacking in predictability/reciprocity
3. Parent ignores, rejects, or fails to comfort the infant
4. Parent does not adequately mirror infant's behavior
5. Parent does not adequately protect the infant, e.g. leaving alone or in the care of a young sibling, or not infant-proofing the home
6. Parent-infant interactions are under-regulated (missed/misinterpreted infant cues)
7. Parent and infant often appear disengaged
8. Infant may appear physically or psychologically un-cared for, e.g. frequent illness, lack of medical care, dirty body or clothing, nonorganic failure to thrive
9. Infant delayed in motor or language skills
10. Affect of both parent and infant is often constricted, withdrawn, sad, and flat
11. Interaction suggests lifelessness and absence of pleasure to the observer
12. Parent may not demonstrate awareness of infant's needs
13. Parent's own relationship history may be characterized by deprivation and/or neglect
• Variation: dyad demonstrates any one from items 1-7 or 11-12 above, with no significant effects on child/family functioning.
• Problem: dyad demonstrates any one from items 1-7 or 11-12 above, plus any one from items 8-10, with moderate effects on child/family functioning.
• Relationship Disorder, Underinvolved Type: dyad demonstrates any two from items 1-7 or 11-12 above, plus any one from items 8-10, with significant effects on infant/family functioning.

Relationship Disorders, Anxious/Tense Type

Parent appears over-sensitive to infant cues, overly concerned about infant, awkward and negative with infant. Both parent and infant may appear anxious, and may overreact to each other. Infant may appear overly compliant

• Key Points
• Reasons for Anxious/Tense Interaction may include: Anxiety about real or perceived threat, e.g. prematurity, chronic illness, past acute illness; Parental anxious personality; Guilt over past behavior including past abortions, angry thoughts or day care placement; Inconsistent control due to parental anxiety, depression or anger; Doesn't understand this baby's cues
• Manifestations
1. Parent's sensitivity to cues is often extremely heightened
2. Parent expresses frequent concerns regarding the infant's well being, behavior, or development and may be overprotective
3. Physical handling of the infant may be awkward or tense
4. May have verbally/emotionally negative interactions
5. Poor fit between the infant's and parent's temperaments or activity levels
6. Infant may be very compliant or anxious around the parent
7. Parent or infant exhibits an anxious mood, as seen in motor tension, apprehension, agitation, facial expressions, and quality of vocalization or speech
8. Both parent and infant overreact, leading to escalation of dysregulating interactions
9. Parent often misinterprets child's behavior and/or affect and consequently responds inappropriately
• Variation: dyad demonstrates any one from items 1-3, 5, or 8-9 above, with no significant effects on child/family functioning.
• Problem: dyad demonstrates any two from items 1-3, 5, or 8-9 above, plus any one from items 6-7, with moderate effects on child/family functioning.
• Relationship Disorder, Anxious/Tense Type: dyad demonstrates any two from items 1-3, 5, or 8-9 above, plus any one from items 6-7, with significant effects on infant/family functioning.

Relationship Disorders, Angry/Hostile Type

Parent appears insensitive to infant cues, perhaps hostile (e.g. teasing or showing resentment toward infant). Infant may demonstrate anxiety, impulsivity, aggression, constricted affect.

• Key Points
• Manifestations
1. Parent may be insensitive to infant's cues
2. Physical handling of the infant is abrupt
3. Parent may taunt or tease the infant
4. Infant may appear frightened, anxious, inhibited, impulsive, or diffusely aggressive
5. Interaction between parent and child typically has hostile/angry edge
6. Moderate to considerable tension between parent and infant
7. Child's affect may be constricted
8. Parent may view child's dependence as demanding and resent child's needs, perhaps due to current stressors or own history
• Variation: dyad demonstrates any one from items 1-3, 9-10, or 12 above, with no significant effects on child/family functioning.
• Problem: dyad demonstrates any two from items 1-3, 9-10, or 12 above, plus any one from items 4-8 or 11, with moderate effects on child/family functioning.
• Relationship Disorder, Angry/Hostile Type: dyad demonstrates any two from items 1-3, 9-10, or 12 above, plus any one from items 4-8 or 11, with significant effects on child/family functioning.

Relationship Disorders, Mixed Type

Parent and infant demonstrate a combination of the above

• Key Points
• Manifestations
• In some cases, dyads will demonstrate relationship problems similar to those described for the other relationship disorders, yet not clearly fitting into any one of these diagnostic categories. In such cases, Relationship Disorder, Mixed Type, should be considered.
• Relationship-based symptoms should be considered a problem when a dyad demonstrates any one parental item plus any one child item from the other relationships disorders described separately, yet does not meet criteria for one of the other relationship 'problems'
• A diagnosis of Relationship Disorder, Mixed, should be considered when a dyad demonstrates any two parental items plus any one child item from the other relationships disorders described separately, yet does not meet criteria for one of the other relationship disorders
• Management
• The clinician should refer to the relationship disorders described separately to access specific management suggestions for families dealing with a diagnosis of Relationship Disorder, Mixed Type

Relationship Disorders, Abusive

Relevant to cases in which concerns are raised regarding parental abuse of child

• Key Points
• Associated factors
• Factors associated with (but NOT inevitably leading to) child abuse include (Kaufman, K. 1989) :
• Abuse in parent's own history
• Parent factors such as low self-esteem, poor cognitive functioning, or poor social skills
• Single parenthood OR conflict with partner
• Child temperamental or behavior problems such as irritability (including those stemming from physical illness or prematurity)
• Poverty, unemployment
• Lack of social support
• Views about children (e.g. belief in physical punishment, view of children as possessions)
• Outcomes associated with abuse
Not surprisingly, abuse in infancy or toddlerhood has been associated with multiple problems in children's later development, including increased risk of cognitive deficits, social deficits such as increased anger and non-compliance, and insecure attachment to parents, compared to non-abused infants and toddlers (Erickson, M.F. 1989)
• Manifestations
• Verbally abusive
• Behavioral Quality of Interaction: The content of verbal/emotional abuse by the parent is intended to severely belittle, blame, attack, overcontrol and reject the infant or toddler; the infant or toddler's reactions may vary widely, from constriction and vigilance to severe acting-out
• Affective Tone: The negative, abusive nature of the parent interaction may be reflected in the infant's depressed, dysregulated, and/or sober affect
• Psychological Involvement: The parent may misinterpret the infant's cries, often viewing these as deliberate negative reactions; Input from the infant may stir up early painful experiences
• A diagnosis of verbal abuse should be considered in cases where any one of the behaviors noted under "behavioral quality of interaction" is observed
• Physically abusive
• Behavioral Quality of Interaction: The parent physically harms the infant or child (e.g. hitting, physical restraint, isolation, extreme punishment); The parent regularly denies the infant or child essentials for survival (e.g. food, medical care, rest); May also include periods of verbal/emotional abuse and/or sexual abuse
• Affective Tone: Anger, hostility, or irritability; Considerable to moderate tension and anxiety between parent and infant; noticeable lack of enthusiasm or enjoyment
• Psychological Involvement: The parent exhibits and/or describes anger or hostility toward the infant through abrupt voice or behavior; The child may evidence a tendency toward concrete behavior rather than the development of fantasy and imagination; aspects of cognition and language may be delayed; The interaction may include periods of closeness or enmeshment and of distance, avoidance, or hostility; Parent and infant may function reasonably well in certain areas, but become either too involved or too distant around certain "triggering" issues
• A diagnosis of physical abuse should be considered in cases where any one of the behaviors noted under "behavioral quality of interaction" is observed
• Sexually abusive
• Behavioral Quality of Interaction: The parent engages in sexually seductive and overstimulating behavior with the infant or young child. These behaviors are intended to gratify the adult's sexual needs or desires. This may include coercing or forcing the infant/toddler to touch or be touched by the parent, or to watch sexual behaviors of others; The young child may evidence sexually driven behaviors such as exhibiting himself or trying to look at or touch other children; This diagnosis may also include periods of verbal/emotional abuse and/or physical abuse
• Affective Tone: The lack of boundaries and consistency in parent-infant interaction may be reflected in the parent's affect, which may be labile. Periods of anger or anxiety may be observable; The infant may appear anxious and/or tense; The young child may be fearful, anxious, or diffusely aggressive
• Psychological Involvement: The parent characteristically does not respond empathically to the infant's needs and cues; The parent has and may evidence extremely distorted thinking, permitting choice of the young infant as a sexual object
• A diagnosis of sexual abuse should be considered in cases where any one of the behaviors noted under "behavioral quality of interaction" is observed
• Management(Handling Anger PT)
From Dubowitz & Newberger (1989):
• Evidence of abuse: medical evidence of child abuse varies widely. Physical findings such as visible injuries or failure to evidence appropriate weight gain should clearly be noted. In many more cases, however, suspicion of abuse may not be confirmed by such physical findings .
• Reporting: physicians are required by law to make a report to Child Protective Services in cases where significant concern exists regarding the possibility of abuse. Physicians cannot be held liable when reports are made in keeping with legal standards. In contrast, physicians who fail to report despite reason for doing so may be held legally liable. Reporting procedures and telephone numbers are provided in the resource database
• In cases in which reports are made, the clinician should ideally remain involved in the case as much as possible. Roles for the clinician in this regard may include providing the family with support and ongoing monitoring, helping parents to develop better skills for managing misbehavior calmly and responding to children's needs appropriately, and making referrals for appropriate support services such as daycare, early intervention programs, or visiting nurses. Some abusing caregivers will need referral for substance use or mental illness.

Nonorganic failure-to-thrive

In some cases, infants will demonstrate a failure to show expected growth and physical development with no known medical cause. The primary cause of nonorganic failure to thrive is a lack of adequate nurturance and interaction between parent and child.

• Key Points
• Benoit (p. 342) highlights the lack of agreement on the definition of failure to thrive, but offers the following general consensus description: "at least a 1-month history of 1) weight below the fifth percentile for age on standardized growth charts and/or 2) deceleration in the rate of weight from birth to the present (downward crossing of at least two major percentiles on standardized growth charts), and 3) weight for height age less than 90%."
• Types: organic failure to thrive (inadequate weight gain due to disease) and nonorganic failure to thrive (inadequate weight gain due to inadequate nurturance, not due to psychological problems in the child). (Schwartz, I.D. 2000) (p. 259), however, points out the potential significance of "mixed failure to thrive," in which a physical problem makes nurturance more challenging. In such cases, the physical problem may predate the problem in the parent-child relationship; alternatively, the sequelae of failure to thrive itself (crankiness, lethargy, etc.) may pose challenges to parental sensitivity. Organic failure to thrive represents approximately 25% of cases, mixed failure to thrive 20% (Benoit, D. 2000)
• Health problems associated with failure to thrive include repeated infections (upper respiratory, GI, etc.) related to compromised immune function secondary to poor nutrition (Schwartz, I.D. 2000) , and neural problems (Benoit, D. 2000) .
• Insecure and disorganized attachment are disproportionately common among children with failure to thrive, compared to controls, e.g. 93% of underweight children demonstrating insecure attachments, compared to 50% of control children (Valenzuela, M. 1990) .
• Between 10 and 20 percent of children with histories of failure to thrive have developmental delay and/or poor academic performance. There are also higher rates of behavior problems.
• Differential diagnosis (Schwartz, I.D. 2000) (p. 260):
• Intrinsic short stature, genetic
• Familial
• Chromosomal abnormalities (trisomy 13, 18, 21; chromosome 22 deletions, gonadal dysgenesis (45,X and variants)
• Skeletal dysplasia
• Intrinsic short stature, intrauterine growth retardation associated with other somatic anomalies
• Russell-Silver
• Prader-Willi
• Cornelia de Lange
• Constitutional delay in growth and development
• Systemic disorders: failure to thrive
• Psychosocial
• Nutritional (Kwashiorkor, Marasmus, Zinc/Iron deficiency)
• Systemic disorders: gastrointestinal
• Feeding disorders (oral-motor apraxia, cleft palate, problems with dentition)
• Vomiting (gastroesophageal reflux, structural anomalies, central nervous system lesion)
• Diarrhea (chronic toddler diarrhea, infectious, malabsorption associated with cystic fibrosis, celiac disease, or inflammatory bowel disease)
• Hepatic (Chronic hepatitis, glycogen storage disease)
• Systemic disorders: infectious
• Tuberculosis
• HIV
• Systemic disorders: Cardiac
• Systemic disorders: Pulmonary
o
• Tonsillar hypertrophy
• Cystic fibrosis
• Systemic disorders: Renal
• Chronic pyelonephritis
• Fanconi syndrome and variants
• Chronic renal insufficiency
• Systemic disorders: Endocrine, younger children
• Hypothyroidism
• Rickets (Vitamin D deficiency, Vitamin D resistance, hypophosphatemic)
• Growth hormone deficiency/resistance
• Systemic disorders: Endocrine, older children
• Hypothyroidism
• Growth hormone deficiency/resistance
• Hypercortisolism
• Pseudohypoparathyroidism
• Type I diabetes mellitus (poorly controlled, Mauriac syndrome)
• Systemic disorders: Central nervous system
• Pituitary insufficiency
• Diencephalic syndrome
• Systemic disorders: Other chronic diseases and treatment thereof
• Oncologic
• Management
• Establish a team approach with caregivers, empathizing with their concern and avoiding judgment.
• Work on the caregiver-child relationship simultaneously with refeeding and conducting any needed medical workup.
• Observe parent-child interaction for play as well as for feeding.
• Interact with the child yourself (without the parent) to determine unusual behaviors.
• Request meeting and observing other adults familiar with the child.
• Appropriate growth charts can be obtained at http://www.cdc.gov/growthcharts
• A detailed dietary history should be taken, including the following information: feeding methods (breast versus bottle); "maternal diet and use of medications that can affect milk production and let-down such as alcohol or diuretics" (Schwartz, I.D. 2000) (p. 259); formula use (including details regarding preparation, consumption, and feeding strategy, to assess over-dilution of or inadequate formula); parental expectations regarding infant caloric intake; other parental attitudes toward food; and juice consumption.
• Medical history should include growth history for all first degree relatives, as well as family history of chromosomal disorders and metabolic disorders.
• A detailed psychosocial history is also critical, including a number of factors that may be associated with growth problems: economic status; stress in the marriage; housing or employment difficulties; homelessness; violence in the home; teenage parents; history of child abuse; and substance abuse in the home.
• Only approximately 10% of failure to thrive cases are found to be associated with an underlying disease. If caregivers are unable to establish adequate nurturing but are not abusive, consider full day daycare with someone who can.
• Address the underlying cause of the failure to thrive while also facilitating increased caloric intake. Calories necessary to achieve "catch-up growth" are estimated as: [120 kcal/kg X (median weight in kg per reference charts/current weight in kg)], with particular attention given to protein, iron, and zinc (Schwartz, I.D. 2000) (p. 262). Formula may be concentrated, powdered milk added, and/or supplemented with glucose polymers (e.g. Polycose) or lipids such as vegetable oil.
• Children >6 months refusing to eat may be exerting their autonomy. Have parents leave finger foods out on a tray for them to eat without comment or reaction. They should also be brought to family meals but their intake not commented on .
• For those patients for whom increased caloric intake is ineffective, tube feedings and gastrostomy may be considered.
• In-home services have demonstrated increased effectiveness relative to outpatient treatment alone.
• Hospitalization may allow for more rapid assessment, as well as more coordinated involvement of "important ancillary staff, including nutritionists, social workers, occupational and physical therapists, therapeutic recreation workers ('child life specialists'), behavioral and developmental specialists and psychologists, and bedside nurses" (Schwartz, I.D. 2000) (p. 263).

Citations

Ainsworth, M.D.S., Blehar, M.C., Waters, E., Wall, S. (1978). Patterns of attachment: A psychological study of the Strange Situation. Benoit, D. (2000). Handbook of Infant Mental Health. Dubowitz, H., Newberger, E. (1989). Child Maltreatment: Theory and research on the causes and consequences of child abuse and neglect. Erickson, M.F., Egeland, B., Pianta, R. (1989). Child Maltreatment: Theory and research on the causes and consequences of child abuse and neglect. Kaufman, K., Zigler, E. (1989). Child Maltreatment: Theory and research on the causes and consequences of child abuse and neglect. Main, M., Solomon, J. (1990). Attachment in the preschool years. Schwartz, I.D. (2000). Failure to thrive: An old nemesis in the new millennium. . Valenzuela, M. (1990). Attachment in chronically underweight young children. . Zeanah, C.H., Mammen, O.K., Lieberman, A.F. (1993). Handbook of Infant Mental Health.