Contents - Previous - Next

4. Conclusions

We have found, in a community survey of infants who were full term births, with birthweights in the normal range, that about 3.5% have growth faltering in the first postnatal year (Skuse, Wolke & Reilly, 1992). To reach our case criteria the degree of growth failure had to be such as to warrant clinical concern, and is equivalent to that seen in previous investigations of hospitalised infants with the condition (see Skuse, 1993c). Yet at the time of our assessment less than 20% of the cases we identified had been referred to hospital for investigation (Skuse, Wolke & Reilly, 1992). Accordingly, the annual incidence figure we report of 3.5% of full term births is considerably higher than might be expected.

At approximately 15 months of age all case children were found to be underweight for their length to some degree. A variety of anthropometric variables which have been shown, in the developing world, to be weakly associated with poverty and malnutrition (e.g. Martorell, Mendoza & Castillo, 1988) were also obtained. They did not show any significant correlation with measures of psychosocial adversity in the families studied in this survey, but this is not surprising as the sample was relatively small. On a variety of criteria the population studied was socioeconomically disadvantaged and other indices of psychosocial adversity were positive indicating families were at relatively high risk of experiencing parenting difficulties. For example, a high proportion of mothers were depressed or suffering from other minor psychiatric disturbance, were living in unsatisfactory accommodation, had relatively low intellectual abilities and a lack of education.

By means of a simple arithmetical procedure it was possible to partition this sample of growth faltering infants into two subgroups: those in whom the onset of the condition was immediately after birth and those for whom it began three to six months later. Remarkably, the outcome in terms of cognitive and psychomotor development, but not in terms of anthropometric criteria, was much worse for those whose growth failure was early. In fact for those in the later group this outcome was not different from a normal comparison group drawn from the same population and closely matched on a wide range of criteria (see Skuse, Wolke & Reilly, 1992). Yet these children who faltered early came from relatively advantaged homes in which the burden of psychosocial adversity was lower than for the later growth faltering subjects.

In conclusion, serious growth faltering during the first postnatal year is more common among full term, otherwise healthy, infants living in a socioeconomically disadvantaged inner city environment than might be expected from the perspective of hospital practice. Their outcome, in terms of cognitive and psychomotor development in the second year of life, seems to be determined primarily be the timing, duration and onset of that growth failure (Skuse et al., 1993). Sustained failure to thrive through the whole period of early childhood, which leads eventually to stunting, is associated with an exceptionally poor outcome for mental abilities (Dowdney et al., 1987). The aetiology of such growth faltering is not simply a matter of nutrition, nor of poor parenting practices. An adequately broad perspective on the subject must also take into account the interaction between behavioural risk factors, a perspective that points the way towards the imperatives of any programme of preventive intervention.

Acknowledgements - This research was supported by grants from the Wellcome Trust, the Child Growth Foundation and the Newcome Educational Foundation, and the work was carried out at the Behavioural Sciences Unit, Institute of Child Health, London.

We thank the staff of Guy's Hospital Community Paediatric service, the Lewisham and North Southwark Health Authority Priority Care Unit and the local general practitioners who actively cooperated with our investigations. Further invaluable assistance with tracing subjects and records was provided by Mrs. Dorothy Gill and Mrs. Jennifer Smith, administrative assistant, who coordinated data collection and prepared the manuscript.


Alabanese A, Hamill G, Jones J, Skuse D, Matthews D & Stanhope R (1993, in press): Reversibility of physiological growth hormone (GH) secretion in children with psychosocial dwarfism. Clinical Endocrinology.

American Psychiatric Association (1993): Diagnostic and statistical manual of mental disorders, 4th ed. Washington, DC: APA.

Amiel-Tison C & Grenier A (1986): Neurological assessment during the first year of life. New York: Oxford University Press.

Antill JK & Cotton S (1982): Spanier's dyadic adjustment scale: Some confirmatory analyses. Aust. Psychol. 17, 181-189.

Bayley N (1969): Bayley Scales of Infant Development. New York: Psychological Corporation.

Bithoney WG & Rathbun J (1983): Failure to thrive. In Developmental behavioral pediatrics, eds M. Levine, W. Carey, A. Crocker et al., pp. 552-557. Philadelphia, PA: W.B. Saunders.

Blodgett FM (1963): Growth retardation related to maternal deprivation. In Modem perspectives in child development, eds J Solnit & SA Provence, pp. 83-93. New York: International University Press Inc.

Brandt I (1986): Growth dynamics of low birthweight infants with emphasis on the perinatal period. In Human growth: A comprehensive treatise, 2nd edn, eds F Faulkner & J Tanner, pp. 415-475. New York: Plenum.

Broman SH, Nichols PL & Kennedy WA (1975): Preschool IQ: prenatal and early developmental correlates. Hillsdale, NJ: Lawrence Erlbaum Associates.

Brooke OG, Anderson HR, Bland JM, Peacock IL Stewart CM (1989): Effects on birth weight of smoking, alcohol, caffeine, socioeconomic factors, and psychosocial stress. Br. Med. J. 298, 795-802.

Cameron N (1984): The measurement of human growth. London: Croom Helm.

Carter B (1985): NEWLONG: a program for manipulation of data in populations of individuals subject to change. Software-practice and experience 15, 369-377.

Casey PH, Bradley R & Wortham B (1984): Social and nonsocial home environments of infants with nonorganic failure to thrive. Pediatrics 73, 348-353.

Coleman RW & Provence S (1957): Environmental retardation (hospitalism) in infants living in families. Pediatrics 19, 285-292.

Department of Health and Social Security (1976): Fit for the future. Report of the Committee on Child Health Services, vol. 1, Chair: Prof. SDM Court, p. 50. London: HMSO.

Dobbing J (1990): Early nutrition and later achievement. Proc. Nutr. Soc. 49, 103-118.

Dobbing J & Smart JL (1974): Vulnerability of developing brain and behaviour. Br. Med. Bull. 30, 164-168.

Dowdney L, Skuse D, Heptinstall E, Puckering C & Zur-Szpiro S (1987): Growth retardation and developmental delay amongst inner-city infants. J. Child Psychol. Psychiatry 28, 529-541.

Drotar D (1985): New directions in failure to thrive. New York: Plenum.

Elmer E (1960): Failure to thrive: Role of the mother. Pediatrics 25, 717-725.

Ferholt JB, Rotnem DL, Genel M, Leonard M, Cary M & Hunter DEK (1985): A psychodynamic study of psychosomatic dwarfism: a syndrome of depression, personality disorder, and impaired growth. J. Am. Acad. Child Adolesc. Psychiatry 24, 49-57.

Field M (1984): Follow-up developmental status of infants hospitalized for nonorganic failure to thrive. J. Pediatr. Psychol. 9, 241-255.

Frank DA (1985): Biologic risks in 'non-organic' failure to thrive: diagnostic and therapeutic implications. In New directions in failure to thrive. Implications for research and practice, ed. D Drotar, pp. 17-26. London: Plenum.

Galler J (1987): Behavioral consequences of malnutrition in early life. In Human nutrition: A comprehensive treatise: Nutrition and behavior, ed. JR Galler, pp. 63-116. New York: Plenum.

Goldberg DP & Hillier VF (1979): A scaled version of the General Health questionnaire. Psychol. Med. 9, 139-145.

Goldberg D & Williams P (1988): A user's guide to the General Health questionnaire. Windsor: NFER-Nelson.

Graves PL (1976): Nutrition, infant behavior, and maternal characteristics: a pilot study in West Bengal, India. Am. J. Clin. Nutr. 29, 305-319.

Green WH, Campbell M & David R (19X4): Psychosocial dwarfism: a critical review of the evidence. J. Am. Acad. Child Adolesc. Psychiatry 23, 39-48.

Green WH, Deutsch SI & Campbell M (1987): Psychosocial dwarfism: psychological and etiological considerations. In Handbook of psychoneuroendocrinology, eds CB Nemeroff & PT Loosen, pp. 109-142. New York: Guilford.

Hamill PVV, Drizd TA, Johnson CL, Reed RB, Roche AF & Moore WM (1979): Physical growth: National Center for Health Statistics percentiles. Am. J. Clin. Nutr. 32, 607-629.

Hertzig ME, Birch HG, Richardson SA & Tizard J (1972): Intellectual measures of school children severely malnourished during the first two years of life. Pediatrics 49, 814-824.

Jordan MD (1986): The CDC anthropometric software package, version 3. Atlanta, GA: Centers for Disease Control.

Kanawati AA & McClaren DS (1970): Assessment of marginal malnutrition. Nature 228, 573-575.

Kitchen WH, Bajuk B, Lissenden JV & Yu VYH (1981): Intra-uterine growth charts from 24-29 weeks gestation. Aust. Paediatr. J. 17, 269-272.

Kotelchuck M (1980): Nonorganic failure to thrive: the status of interactional and environmental etiologic theories, pp. 29-41. Boston, MA: Children's Hospital Medical Centre

Kotelchuck M & Newberger EH (1983): Failure to thrive: a controlled study of familial characteristics. J. Am. Acad. Child Adolesc. Psychiatry 22, 322-328.

Krieger I (1974): Food restriction as a form of child abuse in ten cases of psychosocial deprivation dwarfism. Clin. Pediatr. 13, 127-133.

Leonard MF, Rhymes JP & Solnit AJ (:1966): Failure to thrive in infants: a family problem. Am. J. Dis. Child 111, 600-612.

MacCarthy D (1974): Effects of emotional disturbance and deprivation (maternal rejection) on somatic growth. In Scientific foundations of paediatrics, eds JA Davis & J Dobbing, pp. 56-67. London: Heinemann Medical.

MacCarthy D (1981): The effect of emotional disturbance and deprivation on somatic growth. In Scientific foundations of paediatrics, 2nd edn, eds JA Davis & J Dobbing, pp. 54-73. London: Heinemann Medical.

Marks HG, Borns P, Steg NL, Stine SB, Stroud HH & Vates TS (1978): Catch-up brain growth demonstration by CAT scan. Pediatrics 93, 254-257.

Martorell R (1985): Child growth retardation: a discussion of its causes and its relationship to health. In Nutritional adaptation in man, eds K Blaxter & JC Waterlow, pp. 13-29. London: John Libbey.

Martorell R, Mendoza F & Castillo R (1988): Poverty and stature in children. In Linear growth retardation in less developed countries, ed. J.C. Waterlow, pp. 57-73. Nestle Nutrition Workshop Series, vol. 14. Vevey/New York: Raven Press.

Mathisen B, Skuse D, Wolke D & Reilly S (1989): Oral-motor dysfunction and failure to thrive amongst inner-city children. Dev. Med. Child Neurol. 31, 293-302.

Miller HC & Hassanein K (1971): Diagnosis of impaired fetal growth in newborn infants. Pediatrics 48, 511-521.

Mitchell WG, Gorrell RW & Greenberg RA (1980): Failure-to-thrive: A study in a primary care setting. Epidemiology and follow up. Pediatrics 65, 971-977.

Money J (1992): The Kaspar Hauser syndrome of 'psychosocial dwarfism'. Buffalo, New York: Prometheus Books.

Money J, Annecillo C & Kelley JF (1983): Growth of intelligence: failure and catch-up associated respectively with abuse and rescue in the syndrome of abuse dwarfism. Psychoneuroendocrinology 8, 309-319.

Osborn AF (1987): Assessing the socio-economic status of families. Sociology 21, 429-448.

Osborn A & Morris TC (1979): Rationale for a composite index of social class and its evaluation. Br. J. Sociol. 30, 39-60.

Ounsted M, Moar V & Scott A (1982): Growth in the first year of life: effects of sex and weight for gestational age at birth. Dev. Med. Child Neurol. 24, 356-365.

Patton RG & Gardner LI (1962): Influence of family environment on growth: the syndrome of 'maternal deprivation'. Pediatrics 30, 957-962.

Pollitt E & Leibel RL (1976): Iron deficiency and behaviour. J. Pediatr. 88, 372-381.

Powell GF & Low J (1983): Behaviour in nonorganic failure to thrive. J. Dev. Behav. Pediatr. 4, 26-33.

Powell GF, Hopwood, NJ & Barratt ES (1973): Growth hormone studies before and during catch-up growth in a child with emotional deprivation and short stature. J. Clin. Endocrinol. Metab. 37, 674-679.

Ramey CT, Starr RH, Pallas J, Whitten CF & Reed V (1975): Nutrition, response contingent stimulation, and the maternal deprivation syndrome: results of an early intervention program. Merrill-Palmer Quart. 21, 44-53.

Rees DG, Henry CJK, Diskett P & Shears P (1987): Measures of nutritional status. Lancet i, 87-89.

Reyes MR, Valdecanas CM, Reyes OL & Reyes TM (1990): The effects of malnutrition on the motor, perceptual and cognitive functioning of Filippino children. Int. Disabil. Stud. 12, 131-136.

Rodier PM (1980): Chronology of neuro-development: animal studies and their clinical implications. Dev. Med. Child Neurol. 22, 525-545.

Rona RJ, Chinn S & Manning R (1989): The validity of reported parental height in inner city areas in England. Ann. Hum. Biol. 16, 41-44.

Rutter M (1985): Family and school influences on behavioural development. J. Child Psychol. Psychiatry 26, 349-368.

Sann L, Durand M, Picard J, Lasne Y & Bethenod M (1980): Arm fat and muscle areas in infancy. Arch. Dis. Child. 63, 256-260.

Siimes MA, Addiego JE & Dallman PR (1974): Ferritin in serum: diagnosis of iron deficiency and iron overload in infants and children. Blood 4, 581-590.

Singer LT & Fagan III JF (1984): Cognitive development in the failure-to-thrive infant: A three year longitudinal study. J. Pediatr. Psychol. 9, 363-383.

Skuse D (1989): Psychosocial adversity and impaired growth: in search of causal mechanisms. In The scope of epidemiological psychiatry. Essays in honour of Michael Shepherd, eds P Williams, G Wilkinson & K Rawnsley, pp. 240-263. London: Routledge.

Skuse D (1992): The relationship between deprivation, physical growth and the impaired development of language. In Specific speech and language disorders in children. Correlates, characteristics and outcome, eds P Fletcher & D Hall, pp. 29-50. London: Whurr.

Skuse D (1993a): Abuse and short stature. In ABC of child abuse, 3rd edn, ed. R Meadow, pp. 31-34. London: British Medical Association.

Skuse D (1993b): Emotional abuse and neglect. In ABC of child abuse, 3rd edn, ed. R Meadow, pp. 28-30. London: British Medical Association.

Skuse D (1993c): Epidemiological and definitional issues in failure to thrive. In Child and adolescent psychiatric clinics of North America, ed. J. Woolston, 2(1), 37-59. Philadelphia, PA: Saunders.

Skuse D, Wolke D & Reilly S (1992): Failure to thrive. Clinical and developmental aspects. In Child and youth psychiatry. European perspectives, vol. 2 Developmental psychopathology, eds H Remschmidt & M Schmidt, pp. 46-71. Gottingen: Hogrefe and Huber.

Skuse D, Chan S, Holder S, Stanhope R & Voss L (1993): Diagnostic criteria for 'psychosocial short stature': deriving and validating a diagnostic algorithm.

Skuse D, Pickles A, Wolke D & Reilly S (1993): Postnatal growth and mental development: evidence for a 'sensitive period'. J. Child Psychol. Psychiatr.

South East Thames Regional Health Authority (1984): Statistical and Operational Research Department. District Health Authority ACORN populations.

Spanier GB (1976): Measuring dyadic adjustment: New scales for assessing the quality of marriage and similar dyads. J. Marr. Fam. 38,15-38.

Spanier GB & Thompson L (1982): A confirmatory analysis of the dyadic adjustment scald. J. Marr. Fam. 44, 731-738.

Spitz RA (1945): Hospitalism: an inquiry into the genesis of psychiatric conditions in early childhood. Psychoanal. Study Child 1, 55-74.

Stanhope R, Adlard P, Hamill G, Amos J, Jones J, Skuse D & Preece M (1987): Physiological growth hormone (GH) secretion during recovery from psychosocial dwarfism. J. Endocrinol. 115, Suppl. 21.

Stanhope R, Adlard P, Hamill G, Jones J, Skuse D & Preece MA (1988): Physiological growth hormone (GH) secretion during the recovery from psychosocial dwarfism: a case report. Clin. Endocrinol. 28, 335-339.

Stewart AW, Jackson RT, Ford MA & Beaglehole R (1987): Underestimation of relative weight by use of self-reported height and weight. Am. J. Epidemiol. 125, 122-127.

Talbot NB, Sobel EH, Burke BS, Lindemann E & Kaufman SB (1947): Dwarfism in healthy children: its possible relation to emotional, nutritional and endocrine disturbances. N. Engl. J. Med. 236, 783-793.

Tanner JM & Thomson AM (1970): Standards for birthweight at gestation periods from 32 to 42 weeks allowing for maternal height and weight. Arch. Dis. Child 45, 566-569.

Taylor BJ & Brook CGD (1986): Sleep EEG in growth disorders. Arch. Dis. Child 61, 754-760.

Tietjen AM & Bradley CF (1985): The social networks and social support of married and single mothers in Sweden. J. Marr. Fam. 46, 489-496.

Touwen B (1976): Neurological development in infancy, pp. 1-143. London/Philadelphia: William Heinemann Medical Books Ltd.

Vietze P, Falsey S, O'Connor S, Sandler H, Sherrod K & Altemeier WA (1980): Newborn behavioural and interactional characteristics of nonorganic failure to thrive infants. In High risk infants and children. Adult and peer interactions, ed. T Field, pp. 5-23. New York: Academic Press.

Waldrop MF, Pedersen FA & Bell RQ (1968): Minor physical anomalies and behavior in preschool children. Child Dev. 39, 391-400.

Waldrop MF & Halferson CF (1971): Minor physical anomalies and hyperactive behaviour in young children. In The exceptional infant, vol. 2, ed. J Hellmuth. New York: Brunner/Mazel.

Waterlow J (1984): Current issues in nutritional assessment by anthropometry. In Malnutrition and behavior: Critical assessment of key issues, eds J Brozek & B Schürch pp. 77-90. Lausanne, Switzerland: Nestle Foundation.

Wechsler D (1974): Wechsler Adult Intelligence Scale revised. New York: Psychological Corporation.

Whitten CF, Pettit MG & Fischhoff J (1969): Evidence that growth failure from maternal deprivation is secondary to undereating. J. Am. Med. Wom. Assoc. 209, 1675-1682.

Widdowson EM (1951): Mental contentment and physical growth. Lancet i, 1316-1318.

Wolke D, Skuse D & Mathisen B (1990): Behavioral style in failure to thrive infants: a preliminary communication. J. Pediatr. Psychol. 15, 237-254.

World Health Organization (1972): Nutritional anaemias. Techn. Rep. Series, 503.

World Health Organization (1992): The ICD-10 classification of mental and behavioural disorders. Geneva: World Health Organization.

Yudkin PL, Aboualfa M, Eyre JA, Redman CW & Wilkinson AR (1987): New birthweight and head circumference centiles for gestation ages 24 to 42 weeks. Early Hum. Dev. 15, 45-52.

Zuckerman M & Lubin B (1965): Manual for the MAACL San Diego, CA: Educational and Industrial Testing Service.


The aim of most questions was to obtain further information on Skuse et al.'s study. James wondered if an important cause of growth faltering could have been that the mothers of stunted infants introduced inappropriate foods too early, which could have led to metabolic disturbances. Skuse replied that he and his colleagues had studied dietary intakes in all infants, but that they had found no evidence in support of this hypothesis. On the whole, slightly more of the case infants were breastfed (75% vs 60%) and on average for a longer period (5 vs 3 months) than infants without growth faltering. No important differences in dietary intakes could be found between early and late faltering infants.

There was a negative correlation between a score for minor congenital malformations and the Bayley Mental Development Index, it accounted for about 10% of the variance, but did not distinguish the groups.

The population of South London, where this study was undertaken, is composed of groups of different ethnic backgrounds. Growth faltering was more common in infants from the Indian Subcontinent than among infants of African origin. Asking the parents whether they had wanted another child or not, did not result in different answers for different groups of children.

Waterlow asked Skuse what he thought of MacCarthy's (1981) idea that the hypothalamus and pituitary of neglected and malnourished infants was affected and that this led to stunting via a secondary growth hormone deficiency. According to Skuse, this could be so in cases of psychosocial dwarfism, but these are very rare.


MacCarthy D (1981): The effect of emotional disturbance and deprivation on somatic growth. In Scientific foundations of paediatrics, 2nd edn, eds JA Davis & J Dobbing, pp. 54-73. London: Heinemann Medical.

Contents - Previous - Next