DFCS Online Policies & Procedures

  DFCS Online Policies & Procedures

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Handbook 3: Assessment Guides
3-9 Assessment of Failure to Thrive
Assessment Guides
3-9 Assessment of Failure to Thrive
Reference Points
The Presence of Failure to Thrive on a Child
Parental and Environmental Factors
Suspicion of Failure to Thrive

Reference Points
Effective Date: 03/01/2006
Last Updated: 12/30/2005


Failure to Thrive describes a child who is not developing at the appropriate rate, physically, emotionally, and/or cognitively. There is a failure of physical growth, measured in weight, height, and head circumference; malnutrition; and/or retardation of social and motor development. Failure to Thrive can result in irreversible damage and, in its extreme state, can be fatal. It is a medical condition that must involve a medical doctor’s diagnosis and recommendation for treatment. Infants and babies, age two and younger, are most likely to be victims of Failure to Thrive. However, older children (ages three to twelve) can also be diagnosed as Failure to Thrive (also called psycho-social or derivational dwarfism).

Failure to Thrive is not one disorder, but a spectrum of disorders that have differing etiologies. Traditionally, Failure to Thrive has been classified as organic, non-organic, or mixed. These categories are not usually absolute, in that there is a substantial overlap in children with organic Failure to Thrive experiencing psycho-social difficulties and, similarly, children with non-organic Failure to Thrive experiencing an exacerbation of symptoms and illnesses as a result of organic factors.

Most of the cases that come to the attention of DFCS are diagnosed as Non-organic Failure to Thrive. However, it is important to be aware of organic causes of Failure to Thrive (as diagnosed by medical professionals), to avoid the assumption that these children automatically are being neglected and therefore will need to be detained. As Failure to Thrive is a medical diagnosis, there must be a medical examination and assessment, preferably by a doctor or clinic that specializes in pediatrics and has a thorough knowledge of Failure to Thrive.

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The Presence of Failure to Thrive on a Child  

When a social worker considers the presence of failure to thrive in a child:

  • Consider Organic Failure to Thrive when there may be a medical reason for any symptoms causing concern. 
    • Does the child have any biological conditions such as cystic fibrosis, congenital heart disease, central nervous system abnormalities, gastrointestinal system problems, cleft palate/lip, immunologic diseases, HIV or chronic infections?
  • Consider Mixed Failure to Thrive when there is a combination of both organic and non-organic symptoms causing concern:
    • a. organic cause for any symptoms causing concerns: Has the child been prenatally exposed to drugs/alcohol or maternal infections?
    • During the pregnancy, did the mother have poor nutrition, poor prenatal care or any illnesses?
    • Was the child premature or of low birth weight?
    • Has the child ever attained an average growth pattern?
    • Does the child have problems sucking, swallowing, or feeding?
  • Consider Non-organic Failure to Thrive when there no medical findings to support an organic cause for any symptoms causing concerns:
    • Does the child have abnormal physical features such as little fat on the extremities, lack of muscle in the buttocks, poor muscle tone, bloated stomach, small or short stature, or lack of skin coloring or a head that appears proportionally large to the size of the body?
    • Does the child have excessive diarrhea or severe diaper rash?
    • Does the child present with abnormal eye movements such as poor or no eye contact, glassy eyes, being watchful, wary or wide-eyed with a lack of focus or gaze avoidance?
    • When picked up, does the child arch his/her back, become rigid, pull away, clench his/her hands, or exhibit a scissoring effect (outstretched legs/feet)?
    • When fed, does the child have either a voracious appetite or is anorexic?
    • Does the child display any self-soothing behavior such as rocking, swaying, or self-stimulation play?
    • Is the child appear irritable (especially when handled); apathetic, or listlessness?
    • Is there a lack of spontaneous movement, verbalizations or laughter?
    • Does the child sleep excessively?
    • Does the child have a preference for objects over people?
    • Is the older child delayed in language, or any type of development?
    • Does the child present with bizarre eating habits (stealing, gorging, hiding)?
    • Has there been a change in the child’s growth pattern, e.g., a child whose size was within normal limits at the time of birth may fail to maintain the expected growth pattern?
    • NOTE: When assessing the child, it is essential that (s)he be disrobed, as blankets or clothing can frequently hide the fact that the child is small (low-weight), or may have a severe diaper rash. See Disrobing Children, for additional information and the protocol for disrobing children.
  • Document all essential and pertinent information in the Contact Notebook according to established procedures.
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Parental and Environmental Factors  

When a social worker assesses for parental or environmental factors that may contribute to failure to thrive: 

  • Interview the parent and primary caregiver and observe the caregiver-child interactions for the following: 
    • a. Is there reported maternal depression?
    • Are there any expressions of anger or resentment towards, or rejection of, the child?

    • Is the caregiver or family socially isolated?

    • Is there any conflict or stress related to substance abuse, domestic violence or illness (physical or mental)?

    • Has there been a significant loss in caregiver’s life that has not been worked through?

    • Does the caregiver’s display limited parenting skills (e.g., unaware of cues from infant for food, unrealistic expectations, misinformed regarding nutritional requirements, improper mixing of formula, possible presence of developmental delays)?

    • Does the parent verbalize or display an inability or unwillingness to provide proper feeding, nutrition, bonding, or nurturing?
  • Observe the home and consider:
    • Is there are any visible signs of a child-friendly environment (e.g., crib, or special sleeping-play area, toys, etc.) or is there any visible evidence in the home that a child lives there?
    • NOTE: Bear in mind the role that extreme poverty may play in any lack of resources.
  • Visit the family at mealtime.  Consider: 
    • What type and amount of food is available?
    • Is the food properly prepared and age-appropriate?
    • Are there kitchen appliances available and working?
    • How much, where, and when does the child eat?
    • NOTE: Although there may be sufficient food, emotional rejection, and lack of infant stimulation can be a primary causative factor of Failure to Thrive.
  • Physically interact with the child by holding him or her, attempting to engage the (older) child in play and noting the child’s reactions.
  • Record the home visit according to established procedures and document specific and detailed observations of the child’s environment, appearance and behavior to enhance the referral for a thorough medical assessment, if appropriate.
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Suspicion of Failure to Thrive  

When a social worker suspects failure to thrive in a child: 

  • Consult with the Public Health Nurses (PHNs)according to established procedures.
  • Conduct a joint visit with the PHN in order to further assess the child/caregiver.  Request assistance in: 
    • Obtaining the child’s feeding history from the caregiver as well as the child’s thorough medical history, including birth history, growth charts, medical problems, physical exams, etc.
    • Understanding child’s pertinent developmental milestones, including graphing of a child’s height, weight, and head circumference over time.
    • Locating resources for medical assessments and follow ups, including SCAN teams.
    • Determining a suitable placement, including possible transfer to the Medical Placement Unit, if appropriate
    • NOTE: The SW may often receive a referral from medical sources after the child has been medically diagnosed as Failure to Thrive. However, frequently it is the SW, who is instrumental in making the initial assessment during face-to-face contacts, which results in the child being referred for medical examination, diagnosis and treatment. It is critical that, as soon as Failure to Thrive is suspected, the SW must always involve the Public Health Nurse in the assessment process.
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