Failure to Thrive (FTT), or the dramatic deceleration of appropriate weight gain, delays in height gain, and associated developmental delays (e.g., cognitive and social), occurs in anywhere from 1 to 20 % of children under age five, depending on diagnostic criteria. A child who weighs less than 70% of his/her expected weight is considered a medical emergency, and most children with FTT weigh less than 80% of their expected weight. Causes of FTT are often multi-factorial.  FFT due to neglect and/or maltreatment is also referred to as Psychosocial Dwarfism.

In a set of classic papers in 1967, Powell and colleagues described a group of children with growth retardation and a neuroendocrine profile that mimicked idiopathic hypopituitarism.  The unique characteristic of this group of children was their emotionally abusive caregiving environment.  In 1977, John Money described a similar set of children and coined the phrase "psychosocial dwarfism."  A simple review of the characteristics of these children sounds familiar to any clinician working with severely negelected children: he described : "(1) a history of unusual eating and drinking behavior, reversible on change of domicile, such as eating from a garbage can and drinking from a toilet bowl, stealing food, alleged picky eating and rejecting food at the table, polydipsia and polyphagia, possibly alternating with vomiting and possibly also with self-starvation; (2) a history of such behavioral symptoms as enuresis, encopresis, social apathy or inertia, defiant aggressiveness, sudden tantrums, crying spasms, insomnia, eccentric sleeping and waking schedule, pain agnosia, and self-injury, all occurring only in the growth-retarding environment; (3) retarded motor development, with improvement on removal of the child from the domicile of abuse; (4) retarded intellectual growth, reversible on change of domicile by as much as 30 to 50 IQ points; and (5) a history of pathologic family relationships, including unusual cruelty and neglect, either somatic or psychic or both."

                  By 1984, Green and colleagues again reviewed the evidence connecting developmental neglect and trauma with significant neuroendocrine and growth problems - and again concluded that the growth retardation and unusual neuroendocrine findings in these children was independent of malnutrition.  Yet despite a long heritage of excellent work in this area, published in well-established journals (e.g., New England Journal of Medicine), most physicians continue to be uniformed about the fundamental neuroendocrine, emotional and behavioral problems associated with severely neglected children.

Evidence of child neglect and/or maltreatment's effect on physical growth is robust. Negative parenting (e.g., lack of attention, physical stimulation) has been shown to decrease growth in primates, indicating that psychosocial experiences can affect biological processes. In the original case series of psychosocial dwarfism, putting the children in emotionally supportive and consistent environments reversed growth retardation and the neuroendocrine findings. In more recent studies, children removed from emotionally and physically under-stimulating orphanages before one year of age, who then enter more positive environments, improve dramatically. Even long-term effects (e.g., cognitive effects) become minimal (Johnson et al., 2010).

Unfortunately the long-term effects of untreated neglect-related FTT are pervasive and multi-domain.  Neglect of this magnitude will alter normal development and functioning in all areas of neural functioning. In general the longer the child is in the depriving environment the more pervasive and resistant to reversal are the adverse effects.  Cognitive defects are common and include inability to obtain higher order language or reasoning skills. These cognitive deficits impact the child's ability to logically reason or interact with others. Physical effects such as gastrointestinal problems and disorders related to malnutrition (e.g., marasmus) are also common. The most common consequences, however, and the most resistant to treatment, are the effects of severe early neglect on relational functioning.   

To learn more about FTT and the impact of severe early neglect, visit the CTA website.

Green, W.H., Campbell, M. & David, R. (1984) Psychosocial dwarfism: A critical review of the evidence. J. Amer. Acad. Child Psychiatry 23: 39-48

Johnson, D. E. et al. (2010) Growth and associations between auxology, caregiving environment, and cognition in socially deprived Romanian children randomized to foster vs ongoing institutional care. Archives of Pediatric and Adolescent Medicine, 164, 507- 515.

Money, J. (1977) The syndrome of abuse dwarfism (psychosocial dwarfism or reversible hyposomatotropism): Behavioral data and case report Am J Dis Child. 131(5):508-513

Powell, G.F., Brasel, J.A. & Blizzard, R.M. (1967a) Emotional deprivation and growth retardation simulating idiopathic hypopituitarism. I  Clinical evaluation of the syndrome. New Eng. J. Med 276:1271-1278

Powell, G.F., Brasel, J.A., Raiti, S. & Blizzard, R.M. (1967b)  Emotional deprivation and growth retardation simulating idiopathic hypopituitarism.II Endocrinologic evaluation of the syndrome. New Eng. J. Med. 276: 1279-1283.